CDI Principles and Practice - Chapter 1 correctly answered 2023

CDI Principles and Practice - Chapter 1 correctly answered 2023 Clinical Documentation definition - correct answer any manual or electronic notation made by a physician or other healthcare clinician related to a patient's medical condition or treatment Clinical Documentation improvement - correct answer an activity to enhance the quality of the clinical record --- affecting patient care, reimbursement, severity, and quality scores Quality clinical documentation 7 criteria - correct answer Legible, Reliable, Precise, Complete, Consistent, Clear, Timely What criteria does the below scenario not meet? A physician admits a patient with shortness of breath and chest pain then treats the patient with Lasix, oxygen, and Theophylline. The physician's final documented diagnosis for the patient is acute exacerbation of COP. - correct answer Reliability What criteria does the below scenario not meet? The physician is admitted with chest pain, SOB, fever, and cough. A chest X-ray shows aspiration pneumonia. The physician's final documented diagnosis for the patient is pneumonia - correct answer Precision What criteria does the below scenario not meet? A physician orders comprehensive blood chemistries. The tests show low sodium, magnesium, and potassium levels. The physician does not document diagnoses to represent any of these abnormal results, nor does he document that the results are clinically significant - correct answer Completeness what criteria does the below scenario not meet? The attending physician is asked by the CDI specialist to re-review the neurologist's consultation. The attending physician adds a final progress note to the patient's records that states the final diagnosis is CVA - correct answer Consistency HIPAA - correct answer Health Information Portability and Accountability Act Purpose of HIPAA - correct answer Ensure healthcare coverage for all, safeguard the privacy of clinical info, reduce administrative costs for clinical record keeping 3 necessary part for a CDI program - correct answer implementation, operationalization, and continued maintenance General Lack of High Quality Clinical Documentation Reasons - correct answer 1) Medical School and Residence Programs do not teach clinical documentation practices 2) Importance of physician clinical documentation is not a top priority for healthcare organization 3) The information especially in the inpatient setting is complex 4) Multiple providers are needed when there are longer patient stays results in additional clinical documentation; inconsistent clinical documentation info Evidence-Based Documentation: Theory of High Quality Clinical Documentation - correct answer - The health record must contain info to justify admission and continued hospitalizations, support the diagnosis, and describe the patient's progress and response to medications and services - All patient health record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible All records must document the following: - correct answer 1. A medical history and physical documentation 2. An updated examination of the patient 3. An admitting diagnosis 4. Results of all consultative patient evaluations and appropriate findings by clinical and other staff 5. Documentation of complications