RHIA Exam Prep || Needed to Pass.
Source-Oriented Health Record correct answers Documents organized into sections
according to the provider's and departments that provide treatment (lab together, rad.
together, clinical notes together)
Problem-Oriented Health Record correct answers Divided into four parts: database, problem
list, initial plan, progress notes (SOAP)
SOAP what does S stand for? correct answers Subjective (patient's point of view)
SOAP what does O stand for? correct answers Objective (what the practitioner finds)
SOAP what does A stand for? correct answers Assessment (combine subjective and objective
to make a conclusion)
SOAP what does P stand for? correct answers Plan (approach to be taken to resolve patient's
problem
Integrated Health Records correct answers Documentation from various sources organized in
strict chronological or reverse chronological order
Advantage of Integrated Health Record? correct answers Easy to follow course of diagnosis
and treatment
Disadvantage of Integrated Health Record? correct answers Difficult to compare similar
information (ex. lab results or oncology information)
When should H&P be documented in record? correct answers Within 24 hours of admission
When should Operative Report be documented in record? correct answers Immediately
following surgery
When should Verbal Orders be cosigned? correct answers Within 24 hours
When should Discharge Summary be documented? correct answers Immediately after
discharge of patient
Qualitative Analysis correct answers Review of record to ensure that standards are met and
determine the adequacy of entries documenting the quality of care
Quantitative Analysis correct answers A review of health record to determine its
completeness and accuracy
Data Accuracy correct answers Data are the correct values and are valid
Data Accessibility correct answers Data items are easily obtainable and legal to collect
Data Comprehensiveness correct answers All required data items included AND entire scope
of data is collected and intentional limitations documented
, Data Consistency correct answers Value of data is reliable and consistent across applications
Data Currency correct answers Data is up to date, if it is outdated it must have been up to date
at the time it was presented
Data Definition correct answers Clear definitions provided so users know what data means,
each data element should have clear meaning and accepted values
Data Granularity correct answers The attributes and values of data should be defined at the
correct level of detail
Data Precision correct answers Data values should be just large enough to support the
application or process and acceptable values or ranges must be defined
Data Relevance correct answers The data are meaningful to the performance of the process or
application for which they are collected
Data Timeliness correct answers Determined by how the data are being used and their context
Minimum Data Set (MDS) purpose? correct answers Promote comparability and
compatibility of data by using standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) correct answers Uniform collection of data
on inpatients
Uniform Ambulatory Core Data Set (UACDS) correct answers Improve ability to compare
data in ambulatory care settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument
(RAI) correct answers Comprehensive functional assessment of long-term care patients
Outcome and Assessment Information Set (OASIS) correct answers Comprehensive
assessment for adult home care patient and forms the basis for measuring patient outcomes
Uniform Clinical Data Set (UCDS) correct answers Data collection utilized by peer review
organization to determine the quality of patient care
Data (3 definition points) correct answers 1. Collection of elements on a given subject
2. Raw facts and figures expressed in text, numbers, symbols, and images
3. Facts, ideas, or concepts that can be captured, communicated, and processed, either
manually or electronically
Information (2 definition points) correct answers 1. Data that have been processed into
meaningful form, manually or by computer in order to be valuable to user
2. Adds to a representation and tells recipient something that was not known before
Data Model correct answers Plan or pattern for an information system, including the database
structure, known as a conceptual model, and the translation of the concept to the computer,
known as the physical model
Source-Oriented Health Record correct answers Documents organized into sections
according to the provider's and departments that provide treatment (lab together, rad.
together, clinical notes together)
Problem-Oriented Health Record correct answers Divided into four parts: database, problem
list, initial plan, progress notes (SOAP)
SOAP what does S stand for? correct answers Subjective (patient's point of view)
SOAP what does O stand for? correct answers Objective (what the practitioner finds)
SOAP what does A stand for? correct answers Assessment (combine subjective and objective
to make a conclusion)
SOAP what does P stand for? correct answers Plan (approach to be taken to resolve patient's
problem
Integrated Health Records correct answers Documentation from various sources organized in
strict chronological or reverse chronological order
Advantage of Integrated Health Record? correct answers Easy to follow course of diagnosis
and treatment
Disadvantage of Integrated Health Record? correct answers Difficult to compare similar
information (ex. lab results or oncology information)
When should H&P be documented in record? correct answers Within 24 hours of admission
When should Operative Report be documented in record? correct answers Immediately
following surgery
When should Verbal Orders be cosigned? correct answers Within 24 hours
When should Discharge Summary be documented? correct answers Immediately after
discharge of patient
Qualitative Analysis correct answers Review of record to ensure that standards are met and
determine the adequacy of entries documenting the quality of care
Quantitative Analysis correct answers A review of health record to determine its
completeness and accuracy
Data Accuracy correct answers Data are the correct values and are valid
Data Accessibility correct answers Data items are easily obtainable and legal to collect
Data Comprehensiveness correct answers All required data items included AND entire scope
of data is collected and intentional limitations documented
, Data Consistency correct answers Value of data is reliable and consistent across applications
Data Currency correct answers Data is up to date, if it is outdated it must have been up to date
at the time it was presented
Data Definition correct answers Clear definitions provided so users know what data means,
each data element should have clear meaning and accepted values
Data Granularity correct answers The attributes and values of data should be defined at the
correct level of detail
Data Precision correct answers Data values should be just large enough to support the
application or process and acceptable values or ranges must be defined
Data Relevance correct answers The data are meaningful to the performance of the process or
application for which they are collected
Data Timeliness correct answers Determined by how the data are being used and their context
Minimum Data Set (MDS) purpose? correct answers Promote comparability and
compatibility of data by using standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) correct answers Uniform collection of data
on inpatients
Uniform Ambulatory Core Data Set (UACDS) correct answers Improve ability to compare
data in ambulatory care settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument
(RAI) correct answers Comprehensive functional assessment of long-term care patients
Outcome and Assessment Information Set (OASIS) correct answers Comprehensive
assessment for adult home care patient and forms the basis for measuring patient outcomes
Uniform Clinical Data Set (UCDS) correct answers Data collection utilized by peer review
organization to determine the quality of patient care
Data (3 definition points) correct answers 1. Collection of elements on a given subject
2. Raw facts and figures expressed in text, numbers, symbols, and images
3. Facts, ideas, or concepts that can be captured, communicated, and processed, either
manually or electronically
Information (2 definition points) correct answers 1. Data that have been processed into
meaningful form, manually or by computer in order to be valuable to user
2. Adds to a representation and tells recipient something that was not known before
Data Model correct answers Plan or pattern for an information system, including the database
structure, known as a conceptual model, and the translation of the concept to the computer,
known as the physical model
