RHIA Exam Prep Questions and Answers with Complete Solutions

Document Content and Description Below

RHIA Exam Prep Questions and Answers with Complete Solutions 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 [Show More]

Last updated: 2 years ago

Preview 1 out of 22 pages

Buy Now

Instant download

We Accept: