RHIA Exam Prep Questions and answers Newest RATED A+
2025/2026 UPDATED
Source-Oriented Health Record - Answers 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 - Answers Divided into four parts: database, problem list,
initial plan, progress notes (SOAP)
SOAP what does S stand for? - Answers Subjective (patient's point of view)
SOAP what does O stand for? - Answers Objective (what the practitioner finds)
SOAP what does A stand for? - Answers Assessment (combine subjective and objective to make
a conclusion)
SOAP what does P stand for? - Answers Plan (approach to be taken to resolve patient's
problem
Integrated Health Records - Answers Documentation from various sources organized in strict
chronological or reverse chronological order
Advantage of Integrated Health Record? - Answers Easy to follow course of diagnosis and
treatment
Disadvantage of Integrated Health Record? - Answers Difficult to compare similar information
(ex. lab results or oncology information)
, When should H&P be documented in record? - Answers Within 24 hours of admission
When should Operative Report be documented in record? - Answers Immediately following
surgery
When should Verbal Orders be cosigned? - Answers Within 24 hours
When should Discharge Summary be documented? - Answers Immediately after discharge of
patient
Qualitative Analysis - Answers Review of record to ensure that standards are met and
determine the adequacy of entries documenting the quality of care
Quantitative Analysis - Answers A review of health record to determine its completeness and
accuracy
Data Accuracy - Answers Data are the correct values and are valid
Data Accessibility - Answers Data items are easily obtainable and legal to collect
Data Comprehensiveness - Answers All required data items included AND entire scope of data
is collected and intentional limitations documented
Data Consistency - Answers Value of data is reliable and consistent across applications
Data Currency - Answers Data is up to date, if it is outdated it must have been up to date at the
time it was presented
2025/2026 UPDATED
Source-Oriented Health Record - Answers 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 - Answers Divided into four parts: database, problem list,
initial plan, progress notes (SOAP)
SOAP what does S stand for? - Answers Subjective (patient's point of view)
SOAP what does O stand for? - Answers Objective (what the practitioner finds)
SOAP what does A stand for? - Answers Assessment (combine subjective and objective to make
a conclusion)
SOAP what does P stand for? - Answers Plan (approach to be taken to resolve patient's
problem
Integrated Health Records - Answers Documentation from various sources organized in strict
chronological or reverse chronological order
Advantage of Integrated Health Record? - Answers Easy to follow course of diagnosis and
treatment
Disadvantage of Integrated Health Record? - Answers Difficult to compare similar information
(ex. lab results or oncology information)
, When should H&P be documented in record? - Answers Within 24 hours of admission
When should Operative Report be documented in record? - Answers Immediately following
surgery
When should Verbal Orders be cosigned? - Answers Within 24 hours
When should Discharge Summary be documented? - Answers Immediately after discharge of
patient
Qualitative Analysis - Answers Review of record to ensure that standards are met and
determine the adequacy of entries documenting the quality of care
Quantitative Analysis - Answers A review of health record to determine its completeness and
accuracy
Data Accuracy - Answers Data are the correct values and are valid
Data Accessibility - Answers Data items are easily obtainable and legal to collect
Data Comprehensiveness - Answers All required data items included AND entire scope of data
is collected and intentional limitations documented
Data Consistency - Answers Value of data is reliable and consistent across applications
Data Currency - Answers Data is up to date, if it is outdated it must have been up to date at the
time it was presented
