Clinical Documentation Improvement Intro
and Chapter 1 UPDATED ACTUAL Exam
Questions and CORRECT Answers
What is clinical documentation? - CORRECT ANSWER - any manual or electronic notation
(or recording) made by a physician or other healthcare clinician related to a patient's medical
condition or treatment. Pg. xiii
What is the seven criteria that meets quality clinical documentation? - CORRECT ANSWER -
Legible, Reliable, Precise, Complete, Consistent, Clear, and Timely Pg. xiii
Healthcare organizations are medical trustees for what? - CORRECT ANSWER - Their
patients' protected health information Pg. xiii
What does the acronym HIPAA stand for? - CORRECT ANSWER - Health Information
Portability and Accountability Act pg. xiii
What is the next challenge for the healthcare industry? - CORRECT ANSWER - ensuring
consistency and content and meaning of clinical information as it evolves from manual to an
electronic practice Pg. xiii
What does the acronym PACS? - CORRECT ANSWER - Picture Archive Communication
System
What is the subsequent challenge for the healthcare industry? - CORRECT ANSWER -
digitally compiling all health information about one patient into a common location. Pg xiii
What is the goal of every clinical documentation improvement (CDI) program? - CORRECT
ANSWER - High-quality clinical documentation Pg. xiv
, What is the primary purpose for maintaining a health record? - CORRECT ANSWER -
"accurately and adequately document a patient's life and health history, including the past and
present illness(es) and treatment(s), with emphasis on the events affecting the patients during the
current episode of care." (Huffman 1994, 30). Pg.xiv
what is the primary reference tool for all physicians and clinicians treating the patient? -
CORRECT ANSWER - The health record Pg. xiv
What is the key factor in determining the quality of care provided to the patient? Hint: its the
foundation of the patient's record. - CORRECT ANSWER - Clinical documentation pg. xiv
Who has raised awareness about patients' rights concerning their health information and has
increased the popularity of electronic health records? - CORRECT ANSWER - Health
Information Portability and Accountability Act (HIPPA) pg xv
What is a primary tool for clinicians to communicate with each other about a patient? -
CORRECT ANSWER - A health record pg xv
The typical hospital record includes entries made by whom? - CORRECT ANSWER -
attending physician, specialists, house staff, nurses, radiologists, pathologists, and therapists pg.
xv
What can create a domino effect that negatively impacts the quality of care provided to the
patient? - CORRECT ANSWER - The inaccurate or unreliable clinical documentation of one
provider pg. xv
Who are not thoroughly trained in the principles of high-quality clinical documentation based on
a survey? - CORRECT ANSWER - Medical School Students, residents and most clinicians
pg. xv
What may be the most valuable asset of a healthcare organization? - CORRECT ANSWER -
health records and clinical documentation pg. xv
and Chapter 1 UPDATED ACTUAL Exam
Questions and CORRECT Answers
What is clinical documentation? - CORRECT ANSWER - any manual or electronic notation
(or recording) made by a physician or other healthcare clinician related to a patient's medical
condition or treatment. Pg. xiii
What is the seven criteria that meets quality clinical documentation? - CORRECT ANSWER -
Legible, Reliable, Precise, Complete, Consistent, Clear, and Timely Pg. xiii
Healthcare organizations are medical trustees for what? - CORRECT ANSWER - Their
patients' protected health information Pg. xiii
What does the acronym HIPAA stand for? - CORRECT ANSWER - Health Information
Portability and Accountability Act pg. xiii
What is the next challenge for the healthcare industry? - CORRECT ANSWER - ensuring
consistency and content and meaning of clinical information as it evolves from manual to an
electronic practice Pg. xiii
What does the acronym PACS? - CORRECT ANSWER - Picture Archive Communication
System
What is the subsequent challenge for the healthcare industry? - CORRECT ANSWER -
digitally compiling all health information about one patient into a common location. Pg xiii
What is the goal of every clinical documentation improvement (CDI) program? - CORRECT
ANSWER - High-quality clinical documentation Pg. xiv
, What is the primary purpose for maintaining a health record? - CORRECT ANSWER -
"accurately and adequately document a patient's life and health history, including the past and
present illness(es) and treatment(s), with emphasis on the events affecting the patients during the
current episode of care." (Huffman 1994, 30). Pg.xiv
what is the primary reference tool for all physicians and clinicians treating the patient? -
CORRECT ANSWER - The health record Pg. xiv
What is the key factor in determining the quality of care provided to the patient? Hint: its the
foundation of the patient's record. - CORRECT ANSWER - Clinical documentation pg. xiv
Who has raised awareness about patients' rights concerning their health information and has
increased the popularity of electronic health records? - CORRECT ANSWER - Health
Information Portability and Accountability Act (HIPPA) pg xv
What is a primary tool for clinicians to communicate with each other about a patient? -
CORRECT ANSWER - A health record pg xv
The typical hospital record includes entries made by whom? - CORRECT ANSWER -
attending physician, specialists, house staff, nurses, radiologists, pathologists, and therapists pg.
xv
What can create a domino effect that negatively impacts the quality of care provided to the
patient? - CORRECT ANSWER - The inaccurate or unreliable clinical documentation of one
provider pg. xv
Who are not thoroughly trained in the principles of high-quality clinical documentation based on
a survey? - CORRECT ANSWER - Medical School Students, residents and most clinicians
pg. xv
What may be the most valuable asset of a healthcare organization? - CORRECT ANSWER -
health records and clinical documentation pg. xv
