RHIA Exam Prep Questions And Answers All Correct Distinction Guaranteed2024.

Source-Oriented Health Record - correct 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 - correct answer Divided into four parts: database, problem list, initial plan, progress notes (SOAP) SOAP what does S stand for? - correct answer Subjective (patient's point of view) SOAP what does O stand for? - correct answer Objective (what the practitioner finds) SOAP what does A stand for? - correct answer Assessment (combine subjective and objective to make a conclusion) SOAP what does P stand for? - correct answer Plan (approach to be taken to resolve patient's problem Integrated Health Records - correct answer Documentation from various sources organized in strict chronological or reverse chronological order Advantage of Integrated Health Record? - correct answer Easy to follow course of diagnosis and treatment Disadvantage of Integrated Health Record? - correct answer Difficult to compare similar information (ex. lab results or oncology information) When should H&P be documented in record? - correct answer Within 24 hours of admission When should Operative Report be documented in record? - correct answer Immediately following surgery When should Verbal Orders be cosigned? - correct answer Within 24 hours When should Discharge Summary be documented? - correct answer Immediately after discharge of patient Qualitative Analysis - correct answer Review of record to ensure that standards are met and determine the adequacy of entries documenting the quality of care Quantitative Analysis - correct answer A review of health record to determine its completeness and accuracy Data Accuracy - correct answer Data are the correct values and are valid Data Accessibility - correct answer Data items are easily obtainable and legal to collect Data Comprehensiveness - correct answer All required data items included AND entire scope of data is collected and intentional limitations documented Data Consistency - correct answer Value of data is reliable and consistent across applications Data Currency - correct answer Data is up to date, if it is outdated it must have been up to date at the time it was presented Data Definition - correct answer Clear definitions provided so users know what data means, each data element should have clear meaning and accepted values Data Granularity - correct answer The attributes and values of data should be defined at the correct level of detail Data Precision - correct answer Data values should be just large enough to support the application or process and acceptable values or ranges must be defined Data Relevance - correct answer The data are meaningful to the performance of the process or application for which they are collected Data Timeliness - correct answer Determined by how the data are being used and their context Minimum Data Set (MDS) purpose? - correct answer Promote comparability and compatibility of data by using standard data items with uniform definitions Uniform Hospital Discharge Data Set (UHDDS) - correct answer Uniform collection of data on inpatients Uniform Ambulatory Core Data Set (UACDS) - correct answer Improve ability to compare data in ambulatory care settings Minimum Data Set (MDS) for Long-Term Care (LTC) and Resident Assessment Instrument (RAI) - correct answer Comprehensive functional assessment of long-term care patients Outcome and Assessment Information Set (OASIS) - correct answer Comprehensive assessment for adult home care patient and forms the basis for measuring patient outcomes Uniform Clinical Data Set (UCDS) - correct answer Data collection utilized by peer review organization to determine the quality of patient care Data (3 definition points) - correct answer 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) - correct answer 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 - correct answer 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 - correct answer Persons, locations, things, or concepts about which data can be collected and stored Database Attribute - correct answer Describes an entity or distinct characteristics about it Database Relationship - correct answer Associations between entities Database Character - correct answer Collection of bits make up a byte Byte - correct answer A character such as a number, letter, or symbol Database Field - correct answer Made up of several characters such as name, age, or gender Database Record - correct answer Made up of a series of fields about one person or thing Database File - correct answe