Comprehensive Guide to Preparing for the RHIA Certification Exam

STUDYSAGE

Comprehensive Guide to Preparing for the RHIA Certification
Exam
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




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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




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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


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