RHIA Exam Prep
Source-Oriented Health Record ANS: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 ANS:Divided into four parts: database, problem list, initial plan,
progress notes (SOAP)
SOAP what does S stand for? ANS:Subjective (patient's point of view)
SOAP what does O stand for? ANS:Objective (what the practitioner finds)
SOAP what does A stand for? ANS:Assessment (combine subjective and objective to make a conclusion)
SOAP what does P stand for? ANS:Plan (approach to be taken to resolve patient's problem
Integrated Health Records ANS:Documentation from various sources organized in strict chronological or
reverse chronological order
Advantage of Integrated Health Record? ANS:Easy to follow course of diagnosis and treatment
Disadvantage of Integrated Health Record? ANS:Difficult to compare similar information (ex. lab results
or oncology information)
When should H&P be documented in record? ANS:Within 24 hours of admission
When should Operative Report be documented in record? ANS:Immediately following surgery
When should Verbal Orders be cosigned? ANS:Within 24 hours
When should Discharge Summary be documented? ANS:Immediately after discharge of patient
Qualitative Analysis ANS:Review of record to ensure that standards are met and determine the
adequacy of entries documenting the quality of care
Quantitative Analysis ANS:A review of health record to determine its completeness and accuracy
Data Accuracy ANS:Data are the correct values and are valid
Data Accessibility ANS:Data items are easily obtainable and legal to collect
Data Comprehensiveness ANS:All required data items included AND entire scope of data is collected and
intentional limitations documented
Data Consistency ANS:Value of data is reliable and consistent across applications
, Data Currency ANS:Data is up to date, if it is outdated it must have been up to date at the time it was
presented
Data Definition ANS:Clear definitions provided so users know what data means, each data element
should have clear meaning and accepted values
Data Granularity ANS:The attributes and values of data should be defined at the correct level of detail
Data Precision ANS:Data values should be just large enough to support the application or process and
acceptable values or ranges must be defined
Data Relevance ANS:The data are meaningful to the performance of the process or application for which
they are collected
Data Timeliness ANS:Determined by how the data are being used and their context
Minimum Data Set (MDS) purpose? ANS:Promote comparability and compatibility of data by using
standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) ANS:Uniform collection of data on inpatients
Uniform Ambulatory Core Data Set (UACDS) ANS:Improve ability to compare data in ambulatory care
settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI)
ANS:Comprehensive functional assessment of long-term care patients
Outcome and Assessment Information Set (OASIS) ANS:Comprehensive assessment for adult home care
patient and forms the basis for measuring patient outcomes
Uniform Clinical Data Set (UCDS) ANS:Data collection utilized by peer review organization to determine
the quality of patient care
Data (3 definition points) ANS: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) ANS: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 ANS: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 ANS: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 ANS:Divided into four parts: database, problem list, initial plan,
progress notes (SOAP)
SOAP what does S stand for? ANS:Subjective (patient's point of view)
SOAP what does O stand for? ANS:Objective (what the practitioner finds)
SOAP what does A stand for? ANS:Assessment (combine subjective and objective to make a conclusion)
SOAP what does P stand for? ANS:Plan (approach to be taken to resolve patient's problem
Integrated Health Records ANS:Documentation from various sources organized in strict chronological or
reverse chronological order
Advantage of Integrated Health Record? ANS:Easy to follow course of diagnosis and treatment
Disadvantage of Integrated Health Record? ANS:Difficult to compare similar information (ex. lab results
or oncology information)
When should H&P be documented in record? ANS:Within 24 hours of admission
When should Operative Report be documented in record? ANS:Immediately following surgery
When should Verbal Orders be cosigned? ANS:Within 24 hours
When should Discharge Summary be documented? ANS:Immediately after discharge of patient
Qualitative Analysis ANS:Review of record to ensure that standards are met and determine the
adequacy of entries documenting the quality of care
Quantitative Analysis ANS:A review of health record to determine its completeness and accuracy
Data Accuracy ANS:Data are the correct values and are valid
Data Accessibility ANS:Data items are easily obtainable and legal to collect
Data Comprehensiveness ANS:All required data items included AND entire scope of data is collected and
intentional limitations documented
Data Consistency ANS:Value of data is reliable and consistent across applications
, Data Currency ANS:Data is up to date, if it is outdated it must have been up to date at the time it was
presented
Data Definition ANS:Clear definitions provided so users know what data means, each data element
should have clear meaning and accepted values
Data Granularity ANS:The attributes and values of data should be defined at the correct level of detail
Data Precision ANS:Data values should be just large enough to support the application or process and
acceptable values or ranges must be defined
Data Relevance ANS:The data are meaningful to the performance of the process or application for which
they are collected
Data Timeliness ANS:Determined by how the data are being used and their context
Minimum Data Set (MDS) purpose? ANS:Promote comparability and compatibility of data by using
standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) ANS:Uniform collection of data on inpatients
Uniform Ambulatory Core Data Set (UACDS) ANS:Improve ability to compare data in ambulatory care
settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI)
ANS:Comprehensive functional assessment of long-term care patients
Outcome and Assessment Information Set (OASIS) ANS:Comprehensive assessment for adult home care
patient and forms the basis for measuring patient outcomes
Uniform Clinical Data Set (UCDS) ANS:Data collection utilized by peer review organization to determine
the quality of patient care
Data (3 definition points) ANS: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) ANS: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 ANS: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
