🍎Medical Nutrition Therapy I Unit 3 – Medical Terminology & Charting

Key Concepts and Definitions

• Medical terminology involves the language used to accurately describe the human body and associated components, conditions, processes and procedures in a science-based manner
• Includes prefixes (beginning of a term), suffixes (end of a term), and root words (central meaning) combined to create specific medical terms
• Abbreviations are shortened forms of words or phrases commonly used in medical records and documentation for brevity and efficiency
• Charting encompasses the process of recording patient information, assessments, interventions, and outcomes in a clear, concise, and legally defensible manner
• SOAP notes (Subjective, Objective, Assessment, Plan) provide a structured format for organizing patient information and clinical reasoning in medical records
  • Subjective includes patient-reported symptoms, concerns, and medical history
  • Objective consists of measurable data such as vital signs, physical exam findings, and laboratory results
  • Assessment involves the healthcare provider's diagnosis or clinical impression based on the subjective and objective information
  • Plan outlines the recommended treatment, interventions, education, and follow-up for the patient
• Electronic Health Records (EHRs) are digital versions of patient medical records that facilitate storage, retrieval, and sharing of health information among authorized healthcare providers and institutions

Anatomy and Physiology Basics

• Anatomy refers to the physical structure of the body and its organs, while physiology encompasses the functions and processes carried out by those structures
• Cells are the basic structural and functional units of the body, organized into tissues (groups of similar cells), organs (structures with specific functions), and systems (groups of organs working together)
• Major body systems include the skeletal, muscular, cardiovascular, respiratory, digestive, urinary, reproductive, endocrine, lymphatic, and nervous systems
  • Skeletal system provides structure, support, and protection for the body, and facilitates movement
  • Muscular system enables movement, maintains posture, and generates heat through contraction and relaxation of muscles
  • Cardiovascular system transports blood, nutrients, oxygen, and waste products throughout the body
  • Respiratory system facilitates gas exchange, providing oxygen to the body and removing carbon dioxide
  • Digestive system breaks down food, absorbs nutrients, and eliminates waste
  • Urinary system filters blood, removes waste, and regulates fluid and electrolyte balance
  • Reproductive system enables the production of gametes and, in females, supports the development of offspring
  • Endocrine system produces and secretes hormones to regulate various body functions
  • Lymphatic system helps maintain fluid balance, defends against pathogens, and facilitates the immune response
  • Nervous system receives, processes, and transmits signals to coordinate body functions and respond to internal and external stimuli

Common Medical Abbreviations

• BP (blood pressure): the force exerted by circulating blood against the walls of blood vessels
• HR (heart rate): the number of times the heart beats per minute
• RR (respiratory rate): the number of breaths taken per minute
• T (temperature): the measure of the body's heat, typically in Celsius or Fahrenheit
• Wt (weight): the measurement of body mass, usually in kilograms or pounds
• Ht (height): the measurement of vertical distance from the ground to the top of the head, typically in centimeters or inches
• BMI (body mass index): a measure of body fat based on height and weight, calculated as weight (kg) divided by height (m) squared
• Dx (diagnosis): the identification of a disease, disorder, or condition based on signs, symptoms, and diagnostic tests
• Tx (treatment): the management and care of a patient to combat a disease or disorder
• PRN (pro re nata): a Latin term meaning "as needed" or "as the situation arises," often used in medication orders
• NKDA (no known drug allergies): indicates that the patient has not reported any known allergies to medications
• NPO (nil per os): a Latin term meaning "nothing by mouth," indicating that the patient should not eat or drink

Components of Medical Records

• Demographics include patient identifying information such as name, date of birth, gender, address, and contact information
• Medical history comprises past and current health conditions, surgeries, hospitalizations, allergies, medications, and family health history
• Physical examination findings document the patient's vital signs, general appearance, and results of system-specific assessments performed by the healthcare provider
• Laboratory and diagnostic test results include data from blood tests, imaging studies (X-rays, CT scans, MRIs), biopsies, and other diagnostic procedures
• Treatment plans outline the recommended interventions, medications, therapies, and lifestyle modifications to address the patient's health concerns
• Progress notes chronicle the patient's response to treatment, changes in condition, and any updates to the care plan over time
• Discharge summaries provide an overview of the patient's hospital stay, including the reason for admission, significant findings, treatments provided, and follow-up instructions
• Consent forms document the patient's understanding and agreement to undergo specific treatments, procedures, or participate in research studies

SOAP Note Structure

• Subjective (S): This section includes information reported by the patient, such as their chief complaint, symptoms, concerns, and relevant medical history
  • Consists of patient's description of their condition in their own words
  • Includes the onset, duration, and severity of symptoms, as well as any alleviating or aggravating factors
  • May also encompass the patient's perspective on their health, including any fears, expectations, or goals for treatment
• Objective (O): This section contains measurable and observable data, such as vital signs, physical examination findings, and results from laboratory or diagnostic tests
  • Vital signs typically include blood pressure, heart rate, respiratory rate, and temperature
  • Physical exam findings are organized by body system (e.g., cardiovascular, respiratory, gastrointestinal) and document any abnormalities or pertinent negatives
  • Laboratory and diagnostic test results are recorded with the corresponding reference ranges and any significant deviations from normal
• Assessment (A): This section represents the healthcare provider's synthesis of the subjective and objective information, leading to a diagnosis or clinical impression
  • Involves the provider's critical thinking and clinical reasoning skills to interpret the data and form a conclusion
  • May include a differential diagnosis list, which ranks the possible diagnoses in order of likelihood based on the available information
  • Considers the patient's overall health status, risk factors, and response to previous treatments, if applicable
• Plan (P): This section outlines the healthcare provider's recommended course of action to address the patient's condition, including treatments, medications, referrals, and follow-up
  • Treatment plans are tailored to the individual patient, taking into account their preferences, goals, and any potential barriers to adherence
  • Medications are listed with the specific dose, route, frequency, and duration of administration
  • Referrals to specialists or allied health professionals (e.g., physical therapists, registered dietitians) are made as needed to provide comprehensive care
  • Follow-up instructions specify when the patient should return for re-evaluation or monitoring, and any specific signs or symptoms that warrant earlier contact with the healthcare provider

Nutritional Assessment Documentation

• Anthropometric measurements include height, weight, body mass index (BMI), and waist circumference, which provide insight into the patient's overall nutritional status and body composition
• Biochemical data encompasses laboratory tests that assess nutrient levels, organ function, and markers of disease, such as albumin, prealbumin, electrolytes, glucose, and lipid profiles
• Clinical observations involve the identification of physical signs and symptoms related to nutritional deficiencies or excesses, such as skin changes, hair loss, edema, or muscle wasting
• Dietary intake data is collected through methods such as 24-hour recalls, food frequency questionnaires, or food diaries to evaluate the patient's typical eating patterns, nutrient intake, and any potential deficiencies or excesses
• Environmental and psychosocial factors that may impact nutritional status, such as socioeconomic status, cultural practices, food access, and mental health, are documented to provide context for the patient's nutrition-related challenges and guide appropriate interventions
• Nutrition-focused physical examination (NFPE) is a systematic assessment of the patient's body composition, muscle and fat stores, and any signs of malnutrition or micronutrient deficiencies
  • Includes evaluation of muscle tone, strength, and presence of edema or ascites
  • Assesses skin integrity, wound healing, and any signs of nutrient deficiencies (e.g., glossitis, angular cheilitis)
  • Examines hair, nails, and eyes for signs of nutrient deficiencies or excesses (e.g., sparse hair, brittle nails, pale conjunctiva)
• Nutrition diagnosis statements use standardized language to describe the specific nutrition problem, its etiology, and the signs and symptoms that support the diagnosis
  • Problem (P) describes the nutrition-related issue affecting the patient, such as "inadequate oral intake" or "excessive energy intake"
  • Etiology (E) identifies the cause or contributing factors to the nutrition problem, such as "poor appetite related to chemotherapy" or "limited access to healthy food options"
  • Signs/Symptoms (S) are the observable or measurable indicators that support the nutrition diagnosis, such as "unintentional weight loss" or "elevated blood glucose levels"

Electronic Health Records (EHR) Systems

• EHRs are digital versions of patient medical records that facilitate the storage, retrieval, and sharing of health information among authorized healthcare providers and institutions
• Advantages of EHRs include improved accessibility, legibility, and organization of patient information, as well as the ability to integrate data from multiple sources (e.g., laboratory results, imaging studies) and support clinical decision-making
• Computerized Provider Order Entry (CPOE) allows healthcare providers to enter and manage patient orders, such as medications, tests, and procedures, directly in the EHR system, reducing the risk of errors associated with handwritten orders
• Clinical Decision Support (CDS) tools within EHRs provide real-time guidance and alerts to healthcare providers based on evidence-based guidelines, patient-specific data, and best practices, helping to improve the quality and safety of patient care
• Interoperability refers to the ability of different EHR systems and healthcare organizations to exchange and use patient information seamlessly, enabling coordinated care and reducing the need for redundant tests or procedures
• Privacy and security measures, such as encryption, access controls, and audit trails, are essential components of EHR systems to protect patient confidentiality and comply with regulations such as the Health Insurance Portability and Accountability Act (HIPAA)
• Meaningful Use criteria, established by the Centers for Medicare and Medicaid Services (CMS), define the specific requirements that healthcare providers must meet to qualify for incentive payments related to the adoption and use of certified EHR technology
  • Includes objectives such as using CPOE, exchanging health information electronically, and providing patients with access to their health data
  • Aims to improve the quality, safety, and efficiency of healthcare delivery while engaging patients and families in their care

Legal and Ethical Considerations

• Informed consent is the process by which patients are provided with clear, comprehensive information about a proposed treatment or procedure, including its risks, benefits, and alternatives, and voluntarily agree to undergo the intervention
  • Healthcare providers must ensure that patients have the capacity to make informed decisions and are not under duress or undue influence
  • Informed consent discussions should be documented in the patient's medical record, along with any written consent forms
• Confidentiality refers to the obligation of healthcare providers to protect patients' private health information from unauthorized access, use, or disclosure
  • The Health Insurance Portability and Accountability Act (HIPAA) establishes national standards for the protection of patient privacy and the secure exchange of electronic health information
  • Healthcare providers must adhere to HIPAA regulations, including obtaining patient authorization for the release of protected health information (PHI) and implementing appropriate safeguards to maintain confidentiality
• Scope of practice defines the range of services and procedures that a healthcare professional is legally permitted to perform based on their education, training, and licensure
  • Healthcare providers must practice within the limits of their scope of practice and refer patients to other professionals when necessary to ensure appropriate care
  • Engaging in activities beyond one's scope of practice can result in legal and disciplinary action, as well as potential harm to patients
• Professional boundaries are the limits that define the appropriate relationship between healthcare providers and their patients, maintaining a focus on the patient's well-being and avoiding any exploitation or personal gain
  • Healthcare providers must maintain objectivity and avoid engaging in dual relationships with patients, such as entering into business partnerships or romantic relationships
  • Boundary violations can compromise patient trust, undermine the therapeutic relationship, and lead to legal and ethical consequences for the healthcare provider
• Documentation integrity involves ensuring that patient medical records are accurate, complete, and free from any falsification, alteration, or omission of relevant information
  • Healthcare providers must document all pertinent information related to patient care, including assessments, interventions, and outcomes, in a timely and objective manner
  • Any errors or omissions in documentation should be corrected through proper channels, such as using a single line to strike through the incorrect information and initialing the change, rather than obscuring or destroying the original entry
• Advance directives are legal documents that allow patients to specify their preferences for medical treatment in the event that they become incapacitated and unable to make decisions for themselves
  • Types of advance directives include living wills, which outline the patient's desired or undesired treatments in specific situations, and durable powers of attorney for healthcare, which designate a surrogate decision-maker to act on the patient's behalf
  • Healthcare providers must respect patients' advance directives and incorporate them into the plan of care, while also ensuring that the directives are current and valid under applicable state laws