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Data Currency - ANS-Data is up to date, if it is outdated it must have been up to date at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