CDIP Domain 3: Record Review & Document Clarification with Complete Solutions!

POA - ANSWER-Present on admission Concurrent reviews - ANSWER-CDI specialist reviews the patient record while the patient is in the hospital Ethical - ANSWER-Conforming to accepted standards of conduct Ethical Queries - ANSWER-Queries that do not lead the physician to a particular answer If you have two conflicting diagnoses by two providers, who should make the final decision? - ANSWER-Attending physician Legible - ANSWER-the record is clear enough for the reader to comprehend and easily decipher Reliable - ANSWER-the content of the record is trustworthy, safe, and yielding the same result when repeated Precise - ANSWER-the record is accurate, exact, and strictly defined Complete - ANSWER-the record has the maximum content and is thorough Consistent - ANSWER-the record is not contradictory Clear - ANSWER-the documentation thoroughly describes what is happening with the patient Timely - ANSWER-the record is prepared by the provider at the point it is needed by clinicians for patient care HAC - ANSWER-Hospital Acquired Condition SOI - ANSWER-Severity of Illness ROM - ANSWER-Risk of Mortality Hospital Acquired Conditions - ANSWER-conditions that will not be reimbursed if they occur in the hospital after admission PSIs - ANSWER-Patient Safety Indicators Patient Safety Indicators - ANSWER-set of indicators providing information on potential in-hospital complications and adverse events following surgeries, procedures, and ch