RHIA Exam Prep |285 Questions| With Complete Solutions

Source-Oriented Health Record correct answer: 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 answer: Divided into four parts: database, problem list, initial plan, progress notes (SOAP) Subjective (patient's point of view) correct answer: SOAP what does S stand for? Objective (what the practitioner finds) correct answer: SOAP what does O stand for? Assessment (combine subjective and objective to make a conclusion) correct answer: SOAP what does A stand for? Plan (approach to be taken to resolve patient's problem correct answer: SOAP what does P stand for? Integrated Health Records correct answer: Documentation from various sources organized in strict chronological or reverse chronological order Easy to follow course of diagnosis and treatment correct answer: Advantage of Integrated Health Record? Difficult to compare similar information (ex. lab results or oncology information) correct answer: Disadvantage of Integrated Health Record? Within 24 hours of admission correct answer