RHIA Exam 100% SOLUTION 2025/2026
Source-Oriented Health Record - 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 - Answer - ✔ Divided into four parts: database,
problem list, initial plan, progress notes (SOAP)
SOAP what does S stand for? - Answer - ✔ Subjective (patient's point of view)
SOAP what does O stand for? - Answer - ✔ Objective (what the practitioner finds)
SOAP what does A stand for? - Answer - ✔ Assessment (combine subjective and
objective to make a conclusion)
SOAP what does P stand for? - Answer - ✔ Plan (approach to be taken to resolve
patient's problem
Integrated Health Records - Answer - ✔ Documentation from various sources organized
in strict chronological or reverse chronological order
Advantage of Integrated Health Record? - Answer - ✔ Easy to follow course of
diagnosis and treatment
Disadvantage of Integrated Health Record? - Answer - ✔ Difficult to compare similar
information (ex. lab results or oncology information)
When should H&P be documented in record? - Answer - ✔ Within 24 hours of
admission
When should Operative Report be documented in record? - Answer - ✔ Immediately
following surgery
When should Verbal Orders be cosigned? - Answer - ✔ Within 24 hours
When should Discharge Summary be documented? - Answer - ✔ Immediately after
discharge of patient
Qualitative Analysis - Answer - ✔ Review of record to ensure that standards are met
and determine the adequacy of entries documenting the quality of care
, Quantitative Analysis - Answer - ✔ A review of health record to determine its
completeness and accuracy
Data Accuracy - Answer - ✔ Data are the correct values and are valid
Data Accessibility - Answer - ✔ Data items are easily obtainable and legal to collect
Data Comprehensiveness - Answer - ✔ All required data items included AND entire
scope of data is collected and intentional limitations documented
Data Consistency - Answer - ✔ Value of data is reliable and consistent across
applications
Data Currency - Answer - ✔ Data is up to date, if it is outdated it must have been up to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 - Answer - ✔ Clear definitions provided so users know what data means,
each data element should have clear meaning and accepted values
Data Granularity - Answer - ✔ The attributes and values of data should be defined at the
correct level of detail
Data Precision - Answer - ✔ Data values should be just large enough to support the
application or process and acceptable values or ranges must be defined
Data Relevance - Answer - ✔ The data are meaningful to the performance of the
process or application for which they are collected
Data Timeliness - Answer - ✔ Determined by how the data are being used and their
context
Minimum Data Set (MDS) purpose? - Answer - ✔ Promote comparability and
compatibility of data by using standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) - Answer - ✔ Uniform collection of data
on inpatients
Uniform Ambulatory Core Data Set (UACDS) - Answer - ✔ Improve ability to compare
data in ambulatory care settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment
Instrument (RAI) - Answer - ✔ Comprehensive functional assessment of long-term care
patients
Source-Oriented Health Record - 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 - Answer - ✔ Divided into four parts: database,
problem list, initial plan, progress notes (SOAP)
SOAP what does S stand for? - Answer - ✔ Subjective (patient's point of view)
SOAP what does O stand for? - Answer - ✔ Objective (what the practitioner finds)
SOAP what does A stand for? - Answer - ✔ Assessment (combine subjective and
objective to make a conclusion)
SOAP what does P stand for? - Answer - ✔ Plan (approach to be taken to resolve
patient's problem
Integrated Health Records - Answer - ✔ Documentation from various sources organized
in strict chronological or reverse chronological order
Advantage of Integrated Health Record? - Answer - ✔ Easy to follow course of
diagnosis and treatment
Disadvantage of Integrated Health Record? - Answer - ✔ Difficult to compare similar
information (ex. lab results or oncology information)
When should H&P be documented in record? - Answer - ✔ Within 24 hours of
admission
When should Operative Report be documented in record? - Answer - ✔ Immediately
following surgery
When should Verbal Orders be cosigned? - Answer - ✔ Within 24 hours
When should Discharge Summary be documented? - Answer - ✔ Immediately after
discharge of patient
Qualitative Analysis - Answer - ✔ Review of record to ensure that standards are met
and determine the adequacy of entries documenting the quality of care
, Quantitative Analysis - Answer - ✔ A review of health record to determine its
completeness and accuracy
Data Accuracy - Answer - ✔ Data are the correct values and are valid
Data Accessibility - Answer - ✔ Data items are easily obtainable and legal to collect
Data Comprehensiveness - Answer - ✔ All required data items included AND entire
scope of data is collected and intentional limitations documented
Data Consistency - Answer - ✔ Value of data is reliable and consistent across
applications
Data Currency - 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 - Answer - ✔ Clear definitions provided so users know what data means,
each data element should have clear meaning and accepted values
Data Granularity - Answer - ✔ The attributes and values of data should be defined at the
correct level of detail
Data Precision - Answer - ✔ Data values should be just large enough to support the
application or process and acceptable values or ranges must be defined
Data Relevance - Answer - ✔ The data are meaningful to the performance of the
process or application for which they are collected
Data Timeliness - Answer - ✔ Determined by how the data are being used and their
context
Minimum Data Set (MDS) purpose? - Answer - ✔ Promote comparability and
compatibility of data by using standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) - Answer - ✔ Uniform collection of data
on inpatients
Uniform Ambulatory Core Data Set (UACDS) - Answer - ✔ Improve ability to compare
data in ambulatory care settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment
Instrument (RAI) - Answer - ✔ Comprehensive functional assessment of long-term care
patients
