RHIA Exam Prep Top Rated.

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- Value of data is reliable and consistent across applications Data Currency - Answer - Data is up to date, if it is outdated it must have been up to date at