CDIP From AHIMA's Clinical Documentation Improvement, Achieving Excellence by Ruthann Russo

CDI program data includes: CORRECT ANSWER 1. All cases that were reviewed 2. Number of cases with queries 3. Nature of the query 4. Physician response to the query Queries should only be asked: CORRECT ANSWER 1. If there is clinical evidence that the documentation is incomplete or does not meet one of the seven criteria for high-quality clinical documentation. 2. By an individual with solid clinical knowledge. 3. In an open-ended manner (no yes or no questions) 4. In a nonleading manner. 5. To the individual whose documentation is in question or who is responsible for interpreting test results or other data in the patient's record. Query process and procedure should address: CORRECT ANSWER 1. When queries will be asked. 2. Who will ask queries and to whom queries will be asked. 3. The hospital's responsibility in supporting the querying process. 4. The physician's responsibility in responding to queries. 5. Acceptable ways to responding to queries. Examples of when a query is required may include: CORRECT ANSWER 1. Documentation of reportable conditions or procedures is conflicting, ambiguous, or is otherwise incomplete. 2. Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or higher specificity of an already documented condition. 3. The patient is receiving treatment for a condition that