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RHIA Exam Prep Questions with Answers A+ Graded
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RHIA Exam Prep Questions with Answers A+ Graded
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RHIA Exam Prep Questions withAnswers A+ Graded
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-Data Currency - -Data is up to date, if it is outdated it must have been up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
-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
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