CDIP Domain 3 Record Review and Document Clarification 2023 verified to pass

CDIP Domain 3 Record Review and Document Clarification 7 Criteria for High Quality Documentation - correct answer Legible Reliable Precision complete consistent clarity timeliness Legibility - correct answer Required under all government and regulatory agencies Reliability - correct answer treatment provided without documentation of condition being treated Precision - correct answer no specific diagnosis documented, more specific diagonals appears to be supported completeness - correct answer abnormal test results without documentation for clinic significance (joint commission requirement consistency - correct answer disagreement between two or more treating physicians without obvious resolutions of the conflicting documentation upon discharge clarity - correct answer vague or ambiguous documentation, especially in the case of symptom principal diagnosis timeliness - correct answer documentation that is not complete within the guidelines set by the facility, CMS, state, joint commission, and other regulatory agencies When to Query - correct answer 1. clinical evidence for higher degree of specificity or severity 2. clinical indicators of diagnosis without documentation of the condition 3 cause and effect relationship between two conditions or organism and condition 4. presence of underlying cause when admitted with sypmtoms 5. documentation of only treatment without diagnosis 6. POA indicators 7. Illegibility of documentation 8. site, laterality, type, stage what to include in a query - correct answer patient name, admission date(s) of service, Health record number, account number, date of query, name and contact of CDS/coder, statement of issue what is a statement of issue? - correct answer written as a question, includes clinical indicators from chart, ask provider to make clinical interpretation of facts in chart. Should NOT be presumptive, directing, prodding, probing, or leading When to ask a Yes/No Query - correct answer Determine POA Status substantiating a diagnosis that is already presenting in the health record (other findings) establish or negating a cause and effect relationship resolving conflicting documentation from multiple providers Multiple Choice Queries - correct answer make them open ended, list reasonable choices, Actions to improve response rate to queries - correct answer communication, collaboration, education, physician champion, escalation process Present on Admission (POA) indicators - correct answer Y = Yes N = no U - unknown