CDIP EXAM 1 DOMAIN 3 WITH VERIFIED SOLUTIONS.

A physician documents pneumonia of the left lower lobe with crackles in the bases. The patient has difficulty swallowing day 2 of admission following CVA with infarct. The patient has a history of gastroesophageal reflux. It would be appropriate to query for: A. No query warranted B. Infectious pneumonia C. Aspiration pneumonia D. COPD with pneumonia Aspiration pneumonia Physicians queries should: A. Be initiated on all admissions B. Be leading C. Be utilized to clarify ambiguous documentation D. Be performed by all heath care professionals Be utilized to clarify ambiguous documentation Things to Look Out for When Buying a Used Caravan Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 1:05 Full screen A CDI program should allow concurrent documentation review to: A. educate clinical care providers B. allow providers to clarify hospital acquired conditions and present on admission indicators C. address areas of quality impact D. all of the above all of the above A patient has a stage III pressure ulcer noted in the ED. While the patient is in the hospital for 6 days, the ulcer progresses to stage IV. The correct POA assignment would be: A. Y- yes B. N- No C. U- unknown D. None of the above Y-yes The following query was found in a patient's health record. Which of the answers best applies to this query? Dr. Bean: this patient received IV Rocephin and Vancomycin: please document severe sepsis in the progress note to justify the drug utilization. A. This is a leading query. B. This query brings in information not documented within the chart and is appropriate C. This is a yes or no query D. This is an appropriate query This is a leading query The following query was found in a patient's health record. Which of the answers best applies to this query? Dr. Bean: The patient was admitted with dizziness, coffee-ground emesis and severe, burning abdominal pain. The patient history of gastric ulcers with repeated admissions for alcoholism and habitual use of NSAIDS. Laboratory shows hemoglobin of 10 with transfusion of 2 units RBC's. Patient has anemia. Please document the type of anemia noted within your progress note. A. This is a leading query B. This query brings in information not documented within the chart and is inappropriate C. This is a yes or no query D. This is an appropriate query This is an appropriate query The following query was found in a patient's health record. Which of the answers best applies to this query? Dr. Bean: It was noted within the record that the patient has cellulitis of the foot. Please specify the laterality of the patient's cellulitis. A. This is a leading query B. This query brings in information not documented in the chart C. This is a yes/no query D. This is an appropriate query This is an appropriate query The following query was found in a patient's health record. Which of the answers best applies to this query? Dr. Bean: It is evident within the record that the patient has a diagnosis of CKD stage V. As the patient has a long history of diabetes and hypertension, please document this as the cause of CKD, this patient is is on dialysis. A. This is a leading query B. This query brings in information not documented within the chart and is inappropriate C. This is a yes/no query D. This is an appropriate query This is a leading query The following query was found in the patient's health record. Which of the answers best applies to this query? Dr. Bean: This patient was treated for both a primary neoplasm and a secondary neoplasm based on documentation within the record. Was the focus of the treatment the secondary neoplasm? A. This is a leading query B. This query brings in information not documented within the chart and is inappropriate. C. This is a yes/no query D. This is an appropriate query This is a yes/no query An inpatient undergoes a procedure and has a postoperative complication during the hospitalization. The insurance company will not pay for the entire amount requested. Which POA indicator is likely part of the cause? a. N b. Y c. W d. U N When trying to determine if documentation is present to substantiate status asthmaticus, the coder should review the record for what terms and phrases? A. Intractable pneumonia B. Refractory asthma and severe, intractable wheezing C. Airway obstruction relieved by bronchodilators D. Limited but pronounced wheezing Refractory asthma and severe, intractable wheezing Within the postoperative patient, this is the most common type of shock. It occurs when large amounts of fluid are lost from hemorrhage or severe dehydration. A. Cardiogenic B. Renal C. Hypovolemic D. Neurologic Hypovolemic The procedure that was performed for the definitive treatment (rather then the diagnosis) of the main condition, or complication of the condition is the: A. Chief procedure B. Principal treatment C. Principal procedure D. Comorbidity Principal procedure A physician query may not be appropriate in which of the following instances? A. Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing - Haemophilus influenzae B. Discharge summary indicates chronic renal failure but the progress notes document acute renal failure throughout the stay C. Acute respiratory in s patient whose lab report findings appear to not support the diagnosis D. Diagnosis of chest pain and abnormal cardiac enzymes indicative of AMI Acute respiratory in s patient whose lab report findings appear to not support the diagnosis Who is responsible for the content, quality, and signing of the discharge summary? A. Attending physician B. Head nurse C. Consulting provider D. Admitting nurse Attending physician A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has that the physician should be queried to confirm? a. Insomnia b. Hypertension c. Mental or behavior problems d. Rheumatoid arthritis Mental or behavior problems