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RHIA Exam Prep | Questions And Answers Latest {} A+ Graded | 100% Verified
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RHIA Exam Prep | Questions And Answers Latest {} A+ Graded | 100% Verified
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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Data Currency - Data is up to date, if it is outdated it must have been up to date at the time it was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
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