Answers Updated 2026
Source-OrientedAHealthARecordA-
AAnswerADocumentsAorganizedAintoAsectionsAaccordingAtoAtheAprovider'sAandAdepartments
AthatAprovideAtreatmentA(labAtogether,Arad.Atogether,AclinicalAnotesAtogether)
Problem-OrientedAHealthARecordA-
AAnswerADividedAintoAfourAparts:Adatabase,AproblemAlist,AinitialAplan,AprogressAnotesA(S
OAP)
SOAPAwhatAdoesASAstandAfor?A-AAnswerASubjectiveA(patient'sApointAofAview)
SOAPAwhatAdoesAOAstandAfor?A-AAnswerAObjectiveA(whatAtheApractitionerAfinds)
SOAPAwhatAdoesAAAstandAfor?A-
AAnswerAAssessmentA(combineAsubjectiveAandAobjectiveAtoAmakeAaAconclusion)
SOAPAwhatAdoesAPAstandAfor?A-
AAnswerAPlanA(approachAtoAbeAtakenAtoAresolveApatient'sAproblem
IntegratedAHealthARecordsA-
AAnswerADocumentationAfromAvariousAsourcesAorganizedAinAstrictAchronologicalAorAreverse
AchronologicalAorder
AdvantageAofAIntegratedAHealthARecord?A-
AAnswerAEasyAtoAfollowAcourseAofAdiagnosisAandAtreatment
DisadvantageAofAIntegratedAHealthARecord?A-
AAnswerADifficultAtoAcompareAsimilarAinformationA(ex.AlabAresultsAorAoncologyAinformatio
n)
WhenAshouldAH&PAbeAdocumentedAinArecord?A-AAnswerAWithinA24AhoursAofAadmission
, WhenAshouldAOperativeAReportAbeAdocumentedAinArecord?A-
AAnswerAImmediatelyAfollowingAsurgery
WhenAshouldAVerbalAOrdersAbeAcosigned?A-AAnswerAWithinA24Ahours
WhenAshouldADischargeASummaryAbeAdocumented?A-
AAnswerAImmediatelyAafterAdischargeAofApatient
QualitativeAAnalysisA-
AAnswerAReviewAofArecordAtoAensureAthatAstandardsAareAmetAandAdetermineAtheAadequa
cyAofAentriesAdocumentingAtheAqualityAofAcare
QuantitativeAAnalysisA-
AAnswerAAAreviewAofAhealthArecordAtoAdetermineAitsAcompletenessAandAaccuracy
DataAAccuracyA-AAnswerADataAareAtheAcorrectAvaluesAandAareAvalid
DataAAccessibilityA-AAnswerADataAitemsAareAeasilyAobtainableAandAlegalAtoAcollect
DataAComprehensivenessA-
AAnswerAAllArequiredAdataAitemsAincludedAANDAentireAscopeAofAdataAisAcollectedAandAint
entionalAlimitationsAdocumented
DataAConsistencyA-AAnswerAValueAofAdataAisAreliableAandAconsistentAacrossAapplications
DataACurrencyA-
AAnswerADataAisAupAtoAdate,AifAitAisAoutdatedAitAmustAhaveAbeenAupAtoAdateAatAtheAti
meAitAwasApresented
DataADefinitionA-
AAnswerAClearAdefinitionsAprovidedAsoAusersAknowAwhatAdataAmeans,AeachAdataAelement
AshouldAhaveAclearAmeaningAandAacceptedAvalues