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CDIP Questions and Correct Answers | Latest Update
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CDI program data includes: -:- 1. All cases that were reviewed 2. Number of cases with queries 3. Nature of the query 4. Physician response to the query Queries should only be asked: -:- 1. If there is clinical evidence that the documentation is imcomplete or does not meet one of the s...

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  • September 17, 2024
  • 19
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • cdip questions and correct answers latest updat
  • cdi program data includes 1 all cases that

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2024 /2025 | © copyright | This work may not be copied for profit gain | Excel!




CDIP Questions and Correct Answers | Latest
Update
CDI program data includes:


✓ -:- 1. All cases that were reviewed

✓ 2. Number of cases with queries

✓ 3. Nature of the query

✓ 4. Physician response to the query




Queries should only be asked:


✓ -:- 1. If there is clinical evidence that the documentation is imcomplete

or does not meet one of the seven criteria for high -quality clinical

documentation.

✓ 2. By an individual with solid clinical knowledge.

✓ 3. In an open-ended manner (no yes or no questions)

✓ 4. In a nonleading manner.

✓ 5. To the individual whose documentaion is in question or who is

responible for interpreting test results or other data in the patient's

record.




Query process and procedure should address:


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,2024 /2025 | © copyright | This work may not be copied for profit gain | Excel!



✓ -:- 1. When queries will be asked.

✓ 2. Who will ask queries and to whom queries will be asked.

✓ 3. The hospital's responsibility in supporting the quering process.

✓ 4. The physician's responsibility in responding to queries.

✓ 5. Acceptable ways to responding to qu eries.




Examples of when a query is required may include:


✓ -:- 1. Documentation of reportable conditions or procedures is

conflicting, ambigious, or is otherwise incomplete.

2. Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or

higher specificity of an already documented condition.


3. The patient is receiving treatment for a condition that has not been documented.


4. Abnormal operative or procedureal findings are not documented.


5. It is unclear as to whether a condition was ruled out.


6. The pricipal diagnosis is not clearly identified.




Septicemia




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, 2024 /2025 | © copyright | This work may not be copied for profit gain | Excel!



✓ -:- A systemic disease with the presence and persistence of pathogenic

micro-organisms or toxins in the blood. No longer considere d

synonymous with sepsis.




Sepsis


✓ -:- Sepsis is SIRS due to an infection . Infection can originate anywhere

in the body and be triggered by a bacterial, viral, parasitic, or fungal

infection.




Severe Sepsis


✓ -:- SIRS due to infection with organ dysfun ction.

Sepsis associated with acute dysfunction in one or more organs.


Organ dysfunction bay be cardiovascular, renal, respiratory, hepatic, hematological, central

nervous system, or metabolic acidosis.




SIRS


✓ -:- SIRS is the systemic response to infecti on or trauma.

The systemic response is manifested by a variety of clinical signs and symptoms such as:




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