HIM 5010 Exam 2

Question 1

ARRA

Answer 1

American Recovery and Reinvestment Act of 2009 - Amended the HIPAA rules. The key goal is to create a national standard for the configuration and content of health records so that health information can be easily shared among providers of different organizations. (the goal is complete EHR)

Question 2

Source-Oriented Health Record

Answer 2

Documents are grouped according to their point of origin. Labs with labs, imaging with imaging, progress notes with progress notes, etc.

Question 3

Problem-Oriented Health Record

Answer 3

Is arranged according to a problem list. Each problem is indexed with a unique number, and reports and clinical documentation are keyed to the numbers representing the problems they address. They are arranged in chronological or reverse chronological order.

Question 4

SOAP

Answer 4

Information in progress notes is organized using this sequence.
S - Subjective Information (such as a patient complaint)
O - Objective data (such as diagnostic test results)
A - Assessment (diagnosis)
P - Plan (treatment)

Question 5

Integrated Health Record

Answer 5

Is arranged so that the documentation from various sources is intermingled and follows a strict chronological or reverse chronological order. The advantage is that it’s easy for caregivers to follow the course of the patient’s diagnosis, but difficult to compare related information or to even locate specific information. Used in paper charts.