Exam (elaborations)
RHIA Exam Prep | Questions And Answers Latest {} A+ Graded | 100% Verified
- Course
- Institution
RHIA Exam Prep | Questions And Answers Latest {} A+ Graded | 100% Verified
[Show more]
Content preview
RHIA Exam Prep | Questions And Answers Latest {2024- 2025} A+ Graded | 100%Verified
Source-Oriented Health Record - 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 - Divided into four parts: database, problem list, initial plan, progress
notes (SOAP)
SOAP what does S stand for? - Subjective (patient's point of view)
SOAP what does O stand for? - Objective (what the practitioner finds)
SOAP what does A stand for? - Assessment (combine subjective and objective to make a conclusion)
SOAP what does P stand for? - Plan (approach to be taken to resolve patient's problem
Integrated Health Records - Documentation from various sources organized in strict chronological or
reverse chronological order
Advantage of Integrated Health Record? - Easy to follow course of diagnosis and treatment
Disadvantage of Integrated Health Record? - Difficult to compare similar information (ex. lab results or
oncology information)
When should H&P be documented in record? - Within 24 hours of admission
When should Operative Report be documented in record? - Immediately following surgery
When should Verbal Orders be cosigned? - Within 24 hours
, When should Discharge Summary be documented? - Immediately after discharge of patient
Qualitative Analysis - Review of record to ensure that standards are met and determine the adequacy of
entries documenting the quality of care
Quantitative Analysis - A review of health record to determine its completeness and accuracy
Data Accuracy - Data are the correct values and are valid
Data Accessibility - Data items are easily obtainable and legal to collect
Data Comprehensiveness - All required data items included AND entire scope of data is collected and
intentional limitations documented
Data Consistency - Value of data is reliable and consistent across applications
Data Currency - Data is up to date, if it is outdated it must have been up to date at the time it was
presented
Data Definition - Clear definitions provided so users know what data means, each data element should
have clear meaning and accepted values
Data Granularity - The attributes and values of data should be defined at the correct level of detail
Data Precision - Data values should be just large enough to support the application or process and
acceptable values or ranges must be defined
Data Relevance - The data are meaningful to the performance of the process or application for which
they are collected
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller oneclass. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.48. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
73091 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now