RHIA Exam Prep 2022 with complete solution
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, Data is up to date, if it is outdated it must have been up to date at the time it was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
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
Information (2 definition points)
1. Data that have been processed into meaningful form, manually or by computer in
order to be valuable to user
2. Adds to a representation and tells recipient something that was not known before
Data Model
Plan or pattern for an information system, including the database structure, known as a
conceptual model, and the translation of the concept to the computer, known as the
physical model
Database Entities
Persons, locations, things, or concepts about which data can be collected and stored
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
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
Information (2 definition points)
1. Data that have been processed into meaningful form, manually or by computer in
order to be valuable to user
2. Adds to a representation and tells recipient something that was not known before
Data Model
Plan or pattern for an information system, including the database structure, known as a
conceptual model, and the translation of the concept to the computer, known as the
physical model
Database Entities
Persons, locations, things, or concepts about which data can be collected and stored
