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RHIA Exam Prep Questions and Answers (100% Pass)
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RHIA Exam Prep Questions and Answers (100% Pass)
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©PREP4EXAMS@2024 [REAL EXAM DUMPS] Tuesday, July 23, 2024 10:52 AMRHIA Exam Prep Questions and Answers (100% Pass)
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
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, ©PREP4EXAMS@2024 [REAL EXAM DUMPS] Tuesday, July 23, 2024 10:52 AM
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Data Currency - ✔️✔️Data is up to date, if it is outdated it must have been up to date at the time it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
Data Timeliness - ✔️✔️Determined by how the data are being used and their context
Minimum Data Set (MDS) purpose? - ✔️✔️Promote comparability and compatibility of data by
using standard data items with uniform definitions
Uniform Hospital Discharge Data Set (UHDDS) - ✔️✔️Uniform collection of data on inpatients
Uniform Ambulatory Core Data Set (UACDS) - ✔️✔️Improve ability to compare data in
ambulatory care settings
Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument
(RAI) - ✔️✔️Comprehensive functional assessment of long-term care patients
Outcome and Assessment Information Set (OASIS) - ✔️✔️Comprehensive assessment for adult
home care patient and forms the basis for measuring patient outcomes
Uniform Clinical Data Set (UCDS) - ✔️✔️Data collection utilized by peer review organization to
determine the quality of patient care
Data (3 definition points) - ✔️✔️1. Collection of elements on a given subject
2. Raw facts and figures expressed in text, numbers, symbols, and images
3. Facts, ideas, or concepts that can be captured, communicated, and processed, either manually
or electronically
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