, CDI Clinical Documentation
Improvement 2024 Exam Review
Questions and Answers 100% Pass |
Graded A+
What is a reason a physician documentation can be difficult to
review? - Answer>> Illegible handwriting
The best scientific data available for clinical documentation is also
known as - Answer>> Evidence-based medicine
The two-part theory for high-quality clinical documentation is a
cause-and-effect theory that is derived from which two sources? -
Answer>> Legal/Regulatory Sources and Peer-Reviewed
Research
When discussing completeness in a health record, the physician
has fully addressed all concerns, as well as what other
authentication? - Answer>> Signature and date
Peer-reviewed academic literature states that this factor shows a
relationship to quality of care as well as support for concurrent
CDI programs: - Answer>> Documentation
What evidence supports the lack of high-quality clinical
documentation in the medical field? - Answer>> CDI is not
taught in medical school
Which item is not recommended by the HHS and the OIG for
minimum compliance with clinical documentation regulations? -
Answer>> Physicians should include vaccination records
, What does "reliable" in high-quality clinical documentation mean?
- Answer>> Physician documentation supports medical
treatment
Which item is an important aspect of consistent high-quality
clinical documentation? - Answer>> Creates a clear picture for
subsequent reviewers of documentation
Which aspect of the discharge summary is the biggest challenge
to house staff, mid-level practitioners, and attending physicians as
they compose the patient's discharge summary? - Answer>>
Timeliness
Which aspect of the patient's health record can a member of the
house staff or midlevel practitioner create, yet ultimately needs
the attending physician to confirm accuracy? - Answer>>
Problem list
Interns, residents, and fellows are physicians with lesser
accountability due to their inability to act as an attending physician
and are also known as ______. - Answer>> House staff
Which two medical professionals serve as mid-level practitioners
by supporting physicians in the delivery of care? - Answer>>
Nurse practitioners and physician assistants
In 1982, which aspect of medical billing/reimbursement increased
the demand for accuracy and timeliness with regard to medical
coding? - Answer>> Reimbursement was driven by codes
assigned to patient care
Which hands-on provider's documentation should the coder not
use for final coding? - Answer>> Diagnostic radiologist
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