2026 NHM 365 EXAM 1 QUESTIONS WITH 100%
CORRECT ANSWERS
Parts of the Medical Record -ANSWER-• Demographics
• MD orders (including diet order)
• History and Physical (chief complaint)
• Graphic Sheets (flow sheets)
• Lab reports
• Radiology Reports
• Medication Records
• Progress Notes: MD, Nursing, RD, Social Work, Therapists, etc.
• Consultation Reports
• Discharge Summary
Progress Notes -ANSWER-• Daily updates entered into the medical record
• May be in SOAP, ADIME, narrative, or other formats
• Generally entered by all members of the health care team
• Kept in chronological order
• Includes nutrition care record
Medical Records -ANSWER-• Written documentation of the nutritional care process,
including the interventions and activities used to meet the nutritional objectives
• If it is not documented, it did not happen
• Medical record is a legal document
HIPPAA -ANSWER-Health Insurance Portability and Accountability Act
PHI -ANSWER-• Protected Health Information
,• Written documentation from medical records (including paper records and electronic
databases)
• Spoken or verbal information including voicemail messages
• Photographic images
• Audio and video recordings
EHR -ANSWER-Electronic Health Record
Benefits of Nutrition Care Documentation -ANSWER-• Quality assurance
• Communication among heath care team
• Verifies care given
• Required for Joint Commission accreditation and state audits
ADIME -ANSWER-Assessment, Diagnosis, Intervention, Monitoring, Evaluation
Assessment (ADIME) -ANSWER-• Presents all data pertinent to clinical decision making
• Examples: anthropometrics, abnormalities in appearance or lab values, relevant
medications, etc.
• Should include relevant data only
Diagnosis (ADIME) -ANSWER-• PES (Problem Etiology Signs/Symptoms) Statement for
nutrition diagnosis
• Will use nutrition diagnosis terminology
• Patients may have more than one diagnosis, but try to choose the one or two most
pertinent, or the ones you intend to address
Intervention (ADIME) -ANSWER-• The recommendation or plan that you are doing to
address the nutrition diagnosis
• Recommended change in food-nutrient delivery (NI)
, • Nutrition education (E)
• Nutrition counseling (C)
• Coordination of nutrition care (RC)
Monitoring and Evaluation (ADIME) -ANSWER-• Generally based on signs and symptoms of
your PES statement: weight, intake, lab values, clinical symptoms
• When or how often will you evaluate the effectiveness of your intervention
Narrative Note -ANSWER-• Brief summary of progress, data, action in a paragraph format
• Frequently used to document brief interventions or follow-ups to initial assessments
• The NCP can be applied to this format, too
SOAP -ANSWER-Subjective, Objective, Assessment, Plan
Subjective (SOAP) -ANSWER-• Information provided by patient, family, or other
• Reports of weight loss or gain
• Pertinent socioeconomic information, cultural information, work schedule, etc.
• Level of physical activity
• Significant nutritional history (usual eating pattern, cooking, dining out)
• Work schedule
Objective (SOAP) -ANSWER-• Factual, reproducible observations
• Diagnosis
• Height, weight, age--and documented weight gain/loss patterns
• Clinical data (diarrhea, abdominal dissension, etc.)
• Diet order
• Pertinent medications
• Estimation of nutritional needs
CORRECT ANSWERS
Parts of the Medical Record -ANSWER-• Demographics
• MD orders (including diet order)
• History and Physical (chief complaint)
• Graphic Sheets (flow sheets)
• Lab reports
• Radiology Reports
• Medication Records
• Progress Notes: MD, Nursing, RD, Social Work, Therapists, etc.
• Consultation Reports
• Discharge Summary
Progress Notes -ANSWER-• Daily updates entered into the medical record
• May be in SOAP, ADIME, narrative, or other formats
• Generally entered by all members of the health care team
• Kept in chronological order
• Includes nutrition care record
Medical Records -ANSWER-• Written documentation of the nutritional care process,
including the interventions and activities used to meet the nutritional objectives
• If it is not documented, it did not happen
• Medical record is a legal document
HIPPAA -ANSWER-Health Insurance Portability and Accountability Act
PHI -ANSWER-• Protected Health Information
,• Written documentation from medical records (including paper records and electronic
databases)
• Spoken or verbal information including voicemail messages
• Photographic images
• Audio and video recordings
EHR -ANSWER-Electronic Health Record
Benefits of Nutrition Care Documentation -ANSWER-• Quality assurance
• Communication among heath care team
• Verifies care given
• Required for Joint Commission accreditation and state audits
ADIME -ANSWER-Assessment, Diagnosis, Intervention, Monitoring, Evaluation
Assessment (ADIME) -ANSWER-• Presents all data pertinent to clinical decision making
• Examples: anthropometrics, abnormalities in appearance or lab values, relevant
medications, etc.
• Should include relevant data only
Diagnosis (ADIME) -ANSWER-• PES (Problem Etiology Signs/Symptoms) Statement for
nutrition diagnosis
• Will use nutrition diagnosis terminology
• Patients may have more than one diagnosis, but try to choose the one or two most
pertinent, or the ones you intend to address
Intervention (ADIME) -ANSWER-• The recommendation or plan that you are doing to
address the nutrition diagnosis
• Recommended change in food-nutrient delivery (NI)
, • Nutrition education (E)
• Nutrition counseling (C)
• Coordination of nutrition care (RC)
Monitoring and Evaluation (ADIME) -ANSWER-• Generally based on signs and symptoms of
your PES statement: weight, intake, lab values, clinical symptoms
• When or how often will you evaluate the effectiveness of your intervention
Narrative Note -ANSWER-• Brief summary of progress, data, action in a paragraph format
• Frequently used to document brief interventions or follow-ups to initial assessments
• The NCP can be applied to this format, too
SOAP -ANSWER-Subjective, Objective, Assessment, Plan
Subjective (SOAP) -ANSWER-• Information provided by patient, family, or other
• Reports of weight loss or gain
• Pertinent socioeconomic information, cultural information, work schedule, etc.
• Level of physical activity
• Significant nutritional history (usual eating pattern, cooking, dining out)
• Work schedule
Objective (SOAP) -ANSWER-• Factual, reproducible observations
• Diagnosis
• Height, weight, age--and documented weight gain/loss patterns
• Clinical data (diarrhea, abdominal dissension, etc.)
• Diet order
• Pertinent medications
• Estimation of nutritional needs
