CLINICAL DOCUMENTATION EXAM 5
|HEALTH RECORDS SPECIALIST | LATEST
2025-2026 QUESTION AND CORRECT ANSWER
WITH EXPLANATION WEST COAST
UNIVERSITY
Question 1
A provider documents “acute respiratory failure likely secondary to
opioid overdose.” ABG results are borderline and not clearly documented.
What is the most appropriate CDI action?
A. Code respiratory failure and opioid overdose without review
B. Remove respiratory failure due to lack of objective support
C. Query provider for clinical indicators supporting respiratory failure
D. Code only opioid overdose
Correct Answer: C
Rationale: High-risk diagnoses such as respiratory failure require
objective clinical validation before coding.
Question 2
A chart shows “sepsis” documented in the assessment, but SIRS criteria
are not clearly present. What is the best next step?
A. Code sepsis
B. Ignore diagnosis
C. Query provider for clinical criteria supporting sepsis
D. Code infection only
Correct Answer: C
Rationale: Sepsis requires clinical validation using established criteria
such as organ dysfunction and infection source.
Question 3
Which documentation scenario most strongly supports assignment of
severe sepsis with organ dysfunction?
A. Fever and tachycardia only
B. Infection with elevated WBC only
,C. Infection with hypotension and acute kidney injury
D. Positive culture without symptoms
Correct Answer: C
Rationale: Organ dysfunction such as AKI with infection supports severe
sepsis classification.
Question 4
A physician documents “probable pulmonary embolism” in an outpatient
setting. Imaging is pending. What is the correct coding approach?
A. Code PE
B. Code symptoms only
C. Code probable PE
D. Do not code diagnosis
Correct Answer: B
Rationale: In outpatient settings, uncertain diagnoses are not coded; only
symptoms are reported.
Question 5
A CDI specialist identifies conflicting documentation between discharge
summary and operative report. What takes precedence?
A. Discharge summary
B. Operative report
C. Nursing notes
D. Billing sheet
Correct Answer: B
Rationale: Operative reports are the most authoritative source for
procedural details.
Question 6
A provider documents “acute blood loss anemia post-surgery,” but
hemoglobin drop is not documented. What is the best action?
, A. Code anemia
B. Query provider for clinical evidence
C. Ignore anemia
D. Assign chronic anemia
Correct Answer: B
Rationale: Clinical indicators must support anemia diagnosis for
accurate coding.
Question 7
Which condition most strongly increases MS-DRG weight?
A. Mild dehydration
B. Acute uncomplicated appendicitis
C. Septic shock with organ failure
D. Seasonal allergies
Correct Answer: C
Rationale: Septic shock with organ dysfunction significantly increases
DRG severity.
Question 8
A provider documents “encephalopathy” without etiology or clinical
context. What is the CDI concern?
A. Overcoding risk
B. Lack of specificity requiring clarification
C. Duplicate documentation
D. Non-reimbursable condition
Correct Answer: B
Rationale: Encephalopathy requires an underlying cause for accurate
coding.
Question 9
Which documentation supports accurate assignment of principal
diagnosis?
|HEALTH RECORDS SPECIALIST | LATEST
2025-2026 QUESTION AND CORRECT ANSWER
WITH EXPLANATION WEST COAST
UNIVERSITY
Question 1
A provider documents “acute respiratory failure likely secondary to
opioid overdose.” ABG results are borderline and not clearly documented.
What is the most appropriate CDI action?
A. Code respiratory failure and opioid overdose without review
B. Remove respiratory failure due to lack of objective support
C. Query provider for clinical indicators supporting respiratory failure
D. Code only opioid overdose
Correct Answer: C
Rationale: High-risk diagnoses such as respiratory failure require
objective clinical validation before coding.
Question 2
A chart shows “sepsis” documented in the assessment, but SIRS criteria
are not clearly present. What is the best next step?
A. Code sepsis
B. Ignore diagnosis
C. Query provider for clinical criteria supporting sepsis
D. Code infection only
Correct Answer: C
Rationale: Sepsis requires clinical validation using established criteria
such as organ dysfunction and infection source.
Question 3
Which documentation scenario most strongly supports assignment of
severe sepsis with organ dysfunction?
A. Fever and tachycardia only
B. Infection with elevated WBC only
,C. Infection with hypotension and acute kidney injury
D. Positive culture without symptoms
Correct Answer: C
Rationale: Organ dysfunction such as AKI with infection supports severe
sepsis classification.
Question 4
A physician documents “probable pulmonary embolism” in an outpatient
setting. Imaging is pending. What is the correct coding approach?
A. Code PE
B. Code symptoms only
C. Code probable PE
D. Do not code diagnosis
Correct Answer: B
Rationale: In outpatient settings, uncertain diagnoses are not coded; only
symptoms are reported.
Question 5
A CDI specialist identifies conflicting documentation between discharge
summary and operative report. What takes precedence?
A. Discharge summary
B. Operative report
C. Nursing notes
D. Billing sheet
Correct Answer: B
Rationale: Operative reports are the most authoritative source for
procedural details.
Question 6
A provider documents “acute blood loss anemia post-surgery,” but
hemoglobin drop is not documented. What is the best action?
, A. Code anemia
B. Query provider for clinical evidence
C. Ignore anemia
D. Assign chronic anemia
Correct Answer: B
Rationale: Clinical indicators must support anemia diagnosis for
accurate coding.
Question 7
Which condition most strongly increases MS-DRG weight?
A. Mild dehydration
B. Acute uncomplicated appendicitis
C. Septic shock with organ failure
D. Seasonal allergies
Correct Answer: C
Rationale: Septic shock with organ dysfunction significantly increases
DRG severity.
Question 8
A provider documents “encephalopathy” without etiology or clinical
context. What is the CDI concern?
A. Overcoding risk
B. Lack of specificity requiring clarification
C. Duplicate documentation
D. Non-reimbursable condition
Correct Answer: B
Rationale: Encephalopathy requires an underlying cause for accurate
coding.
Question 9
Which documentation supports accurate assignment of principal
diagnosis?
