CDEO UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS COMPREHENSIVE
STUDY GUIDE
●● Individuals protected health information
Answer: Demographic data, name, address, birth date, and SS number.
●● central focus of clinical documentation
Answer: should be to demonstrate the quality of care provided to the
patient with detail and accuracy to facilitate optimum patient care.
●● CDEO Focus
Answer: Clinical documentation improvement is a proactive measure.
The CDS will develop and monitor policies and procedures that affect
the documentation process. CDI should begin at the front end of all
services and care. Prevention of documentation issues is the key.
●● CDEO Review
Answer: The CDEO will review the findings of the auditor to determine
what should be done to resolve documentation the issues on a proactive
basis to prevent documentation and compliance risks.
●● Other request than Federal Healthplans
,Answer: For different reasons other than reimbursement, requests for
medical records come from different sources, for a multitude of different
reasons. A few of these, other than Federal Health Care Plans, are
patients who are becoming more active in their care , attorneys seeking
information for third party liability claims or mal-practice claims, other
providers involved in the patients' care, employers for pre-employment
applications and worker's compensation cases, private payers, recruiting
offices for military applications, and the social security administration
for the patients' SSI applications.
●● The appropriateness of the services provided
Answer: In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what
services were actually provided. Other than the site of service the
medical record may be used to validate:
●● Medical Record Validates
Answer: In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what
services were actually provided. The medical record may be used to
validate: (a) The site of the service; (b) The appropriateness of the
services provided; (c) The accuracy of the billing; and (d) The identity of
the caregiver.
●● Detailed, well documented notes
,Answer: The details in a well-documented note are a provider's best
defense in any legal situation. If the record is deficient in details, there is
no "evidence" to support a provider's testimony.
●● During the encounter or as soon as possible
Answer: To maintain an accurate medical record, what is the
recommended appropriate time for provider documentation?
●● If it is documented in the patient's medical record
Answer: Quality assurance of patient care is only evident if:
●● CDI Programs intent
Answer: CDI programs are intended to be performed on a prospective
basis to improve documentation deficiencies prior to claim submission.
The intent is to identify deficiencies and make the appropriate
corrections and prevent future deficiencies. CDI programs can also
include retrospective reviews.
●● It encourages physician participation.
Answer: Why is it important to involve physicians in Clinical
Documentation Improvement (CDI) programs?
●● Failure to include the instructions for post procedure care and
potential complications.
, Answer: Which of the following documentation deficiencies has a
negative impact on patient outcomes?
●● Provide examples of the provider's documentation deficiencies with
suggestions for improvement.
Answer: What is an effective method for communicating documentation
deficiencies to a provider?
●● Improve patient outcomes, Improve patient outcomes, and improve
the provider query process.
Answer: Which of the following is/are considered a purpose of
documentation improvement programs?
●● How can an effective CDI program improve patient outcomes?
Answer: The main goal for detailed medical records is to promote the
continuity of care for the patient. This allows providers to communicate
with each other on the care that has been provided to the patient. Coding
higher level services that are not medically necessary is not a goal to
improve patient outcomes.
●● Which of the following recommendations should be made to
providers regarding the patient's problem list?
Answer: Problem lists should be updated when a significant change
takes place to make sure the information on the problem list is still
current and accurate. A common problem is the list is created but it is not
maintained so it becomes difficult to know which conditions are current
CORRECT ANSWERS COMPREHENSIVE
STUDY GUIDE
●● Individuals protected health information
Answer: Demographic data, name, address, birth date, and SS number.
●● central focus of clinical documentation
Answer: should be to demonstrate the quality of care provided to the
patient with detail and accuracy to facilitate optimum patient care.
●● CDEO Focus
Answer: Clinical documentation improvement is a proactive measure.
The CDS will develop and monitor policies and procedures that affect
the documentation process. CDI should begin at the front end of all
services and care. Prevention of documentation issues is the key.
●● CDEO Review
Answer: The CDEO will review the findings of the auditor to determine
what should be done to resolve documentation the issues on a proactive
basis to prevent documentation and compliance risks.
●● Other request than Federal Healthplans
,Answer: For different reasons other than reimbursement, requests for
medical records come from different sources, for a multitude of different
reasons. A few of these, other than Federal Health Care Plans, are
patients who are becoming more active in their care , attorneys seeking
information for third party liability claims or mal-practice claims, other
providers involved in the patients' care, employers for pre-employment
applications and worker's compensation cases, private payers, recruiting
offices for military applications, and the social security administration
for the patients' SSI applications.
●● The appropriateness of the services provided
Answer: In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what
services were actually provided. Other than the site of service the
medical record may be used to validate:
●● Medical Record Validates
Answer: In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what
services were actually provided. The medical record may be used to
validate: (a) The site of the service; (b) The appropriateness of the
services provided; (c) The accuracy of the billing; and (d) The identity of
the caregiver.
●● Detailed, well documented notes
,Answer: The details in a well-documented note are a provider's best
defense in any legal situation. If the record is deficient in details, there is
no "evidence" to support a provider's testimony.
●● During the encounter or as soon as possible
Answer: To maintain an accurate medical record, what is the
recommended appropriate time for provider documentation?
●● If it is documented in the patient's medical record
Answer: Quality assurance of patient care is only evident if:
●● CDI Programs intent
Answer: CDI programs are intended to be performed on a prospective
basis to improve documentation deficiencies prior to claim submission.
The intent is to identify deficiencies and make the appropriate
corrections and prevent future deficiencies. CDI programs can also
include retrospective reviews.
●● It encourages physician participation.
Answer: Why is it important to involve physicians in Clinical
Documentation Improvement (CDI) programs?
●● Failure to include the instructions for post procedure care and
potential complications.
, Answer: Which of the following documentation deficiencies has a
negative impact on patient outcomes?
●● Provide examples of the provider's documentation deficiencies with
suggestions for improvement.
Answer: What is an effective method for communicating documentation
deficiencies to a provider?
●● Improve patient outcomes, Improve patient outcomes, and improve
the provider query process.
Answer: Which of the following is/are considered a purpose of
documentation improvement programs?
●● How can an effective CDI program improve patient outcomes?
Answer: The main goal for detailed medical records is to promote the
continuity of care for the patient. This allows providers to communicate
with each other on the care that has been provided to the patient. Coding
higher level services that are not medically necessary is not a goal to
improve patient outcomes.
●● Which of the following recommendations should be made to
providers regarding the patient's problem list?
Answer: Problem lists should be updated when a significant change
takes place to make sure the information on the problem list is still
current and accurate. A common problem is the list is created but it is not
maintained so it becomes difficult to know which conditions are current
