Discuss the purpose and give an example of charting by exception in the patient's medical record
Charting by exception (CBE) is an abbreviated approach to medical charting that involves recording only unusual or out-of-the-ordinary events. The CBE format includes a standardized nutritional care plan. After the initial charting of the care plan, only significant data and/or unanticipated responses to the proposed plan should be included in the record. In most CBE formats, a flowchart is used to document assessments and interventions. An asterisk (*) indicates an abnormal finding on an assessment or an abnormal response to an intervention. The findings are explained in the comments section of the form. An example of CBE might be documenting on a patient who has been vomiting; the dietitian fills out the flow chart and then writes an asterisk in the GI section. In the notes, the dietitian may then write: * "Pt. has vomited three times this morning…" and go on to explain the cause and effects of the situation.
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Factors that increase the risk of malnutrition include:
a. time spent watching television. b. presence of grandparents in the home. c. sedentary occupations. d. heavy physical labor.
The key motivating factor in the selection of food is lower fat and balanced nutrient intake.
Answer the following statement true (T) or false (F)
Juan knows that he only eats a small number of foods and that he mostly eats junk foods. Therefore he needs
A) excessive amounts of the needed nutrients. B) megadoses of the needed nutrients. C) more of the needed nutrients. D) adequate amounts of the needed nutrients.
Which of the following groups of foods includes items that are good sources of riboflavin?
A. Grains B. Vegetables C. Oils D. Fruits