RHIA Exam Prep 2026 Questions and
Answers
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
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,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
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
, 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Data Currency - Correct answer-Data is up to date, if it is outdated it must have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
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
Answers
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
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,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
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
, 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
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
