RHIA Exam Prep with all Correct & 100% Verified
Answers |Actual Complete Exam| Already Graded A+
(Just Released)
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)
SOAP what does S stand for? ✔Correct Answer-Subjective (patient's point of view)
SOAP what does O stand for? ✔Correct Answer-Objective (what the practitioner finds)
SOAP what does A stand for? ✔Correct Answer-Assessment (combine subjective and objective to
make a conclusion)
SOAP what does P stand for? ✔Correct Answer-Plan (approach to be taken to resolve patient's
problem
Integrated Health Records ✔Correct Answer-Documentation from various sources organized in
strict chronological or reverse chronological order
Advantage of Integrated Health Record? ✔Correct Answer-Easy to follow course of diagnosis and
treatment
Disadvantage of Integrated Health Record? ✔Correct Answer-Difficult to compare similar
information (ex. lab results or oncology information)
When should H&P be documented in record? ✔Correct Answer-Within 24 hours of admission
When should Operative Report be documented in record? ✔Correct Answer-Immediately following
surgery
When should Verbal Orders be cosigned? ✔Correct Answer-Within 24 hours
When should Discharge Summary be documented? ✔Correct Answer-Immediately after discharge
of patient
Qualitative Analysis ✔Correct Answer-Review of record to ensure that standards are met and
determine the adequacy of entries documenting the quality of care
Quantitative Analysis ✔Correct Answer-A review of health record to determine its completeness
and accuracy
Data Accuracy ✔Correct Answer-Data are the correct values and are valid
, Data Accessibility ✔Correct Answer-Data items are easily obtainable and legal to collect
Data Comprehensiveness ✔Correct Answer-All required data items included AND entire scope of
data is collected and intentional limitations documented
Data Consistency ✔Correct Answer-Value of data is reliable and consistent across applications
Data Currency ✔Correct Answer-Data is up to date, if it is outdated it must have been up to date at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 Answer-Clear definitions provided so users know what data means, each
data element should have clear meaning and accepted values
Data Granularity ✔Correct Answer-The attributes and values of data should be defined at the
correct level of detail
Data Precision ✔Correct Answer-Data values should be just large enough to support the
application or process and acceptable values or ranges must be defined
Data Relevance ✔Correct Answer-The data are meaningful to the performance of the process or
application for which they are collected
Data Timeliness ✔Correct Answer-Determined by how the data are being used and their context
Minimum Data Set (MDS) purpose? ✔Correct Answer-Promote comparability and compatibility of
data by using standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) ✔Correct Answer-Uniform collection of data on
inpatients
Uniform Ambulatory Core Data Set (UACDS) ✔Correct Answer-Improve ability to compare data in
ambulatory care settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI)
✔Correct Answer-Comprehensive functional assessment of long-term care patients
Outcome and Assessment Information Set (OASIS) ✔Correct Answer-Comprehensive assessment
for adult home care patient and forms the basis for measuring patient outcomes
Uniform Clinical Data Set (UCDS) ✔Correct Answer-Data collection utilized by peer review
organization to determine the quality of patient care
Data (3 definition points) ✔Correct Answer-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 Answer-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
Answers |Actual Complete Exam| Already Graded A+
(Just Released)
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)
SOAP what does S stand for? ✔Correct Answer-Subjective (patient's point of view)
SOAP what does O stand for? ✔Correct Answer-Objective (what the practitioner finds)
SOAP what does A stand for? ✔Correct Answer-Assessment (combine subjective and objective to
make a conclusion)
SOAP what does P stand for? ✔Correct Answer-Plan (approach to be taken to resolve patient's
problem
Integrated Health Records ✔Correct Answer-Documentation from various sources organized in
strict chronological or reverse chronological order
Advantage of Integrated Health Record? ✔Correct Answer-Easy to follow course of diagnosis and
treatment
Disadvantage of Integrated Health Record? ✔Correct Answer-Difficult to compare similar
information (ex. lab results or oncology information)
When should H&P be documented in record? ✔Correct Answer-Within 24 hours of admission
When should Operative Report be documented in record? ✔Correct Answer-Immediately following
surgery
When should Verbal Orders be cosigned? ✔Correct Answer-Within 24 hours
When should Discharge Summary be documented? ✔Correct Answer-Immediately after discharge
of patient
Qualitative Analysis ✔Correct Answer-Review of record to ensure that standards are met and
determine the adequacy of entries documenting the quality of care
Quantitative Analysis ✔Correct Answer-A review of health record to determine its completeness
and accuracy
Data Accuracy ✔Correct Answer-Data are the correct values and are valid
, Data Accessibility ✔Correct Answer-Data items are easily obtainable and legal to collect
Data Comprehensiveness ✔Correct Answer-All required data items included AND entire scope of
data is collected and intentional limitations documented
Data Consistency ✔Correct Answer-Value of data is reliable and consistent across applications
Data Currency ✔Correct Answer-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 Answer-Clear definitions provided so users know what data means, each
data element should have clear meaning and accepted values
Data Granularity ✔Correct Answer-The attributes and values of data should be defined at the
correct level of detail
Data Precision ✔Correct Answer-Data values should be just large enough to support the
application or process and acceptable values or ranges must be defined
Data Relevance ✔Correct Answer-The data are meaningful to the performance of the process or
application for which they are collected
Data Timeliness ✔Correct Answer-Determined by how the data are being used and their context
Minimum Data Set (MDS) purpose? ✔Correct Answer-Promote comparability and compatibility of
data by using standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) ✔Correct Answer-Uniform collection of data on
inpatients
Uniform Ambulatory Core Data Set (UACDS) ✔Correct Answer-Improve ability to compare data in
ambulatory care settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI)
✔Correct Answer-Comprehensive functional assessment of long-term care patients
Outcome and Assessment Information Set (OASIS) ✔Correct Answer-Comprehensive assessment
for adult home care patient and forms the basis for measuring patient outcomes
Uniform Clinical Data Set (UCDS) ✔Correct Answer-Data collection utilized by peer review
organization to determine the quality of patient care
Data (3 definition points) ✔Correct Answer-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 Answer-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
