RHIA Exam Prep Questions and
Answers 100% Pass
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
COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED
, 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Data Currency - CORRECT ANSWER-Data is up to date, if it is outdated it must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
Answers 100% Pass
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
COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED
, 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
