Certified Documentation Integrity
Practitioner (CDIP) exam-style questions and
answers.
CDIP Exam Questions and Answers
Multiple Choice Questions
1. What is the primary objective of the Certified Documentation Integrity
Practitioner (CDIP)?
A) To audit financial statements
B) To ensure the accuracy, consistency, and integrity of clinical documentation
C) To implement electronic health record software
D) To train medical staff on patient communication
Answer: B) To ensure the accuracy, consistency, and integrity of clinical
documentation
2. Which of the following is considered a key responsibility of a CDIP?
A) Performing surgical procedures
B) Reviewing and validating medical documentation for compliance
C) Prescribing medications
D) Managing hospital billing software
Answer: B) Reviewing and validating medical documentation for compliance
3. Which standard is most commonly referenced for documentation integrity in
healthcare?
A) HIPAA (Health Insurance Portability and Accountability Act)
B) OSHA (Occupational Safety and Health Administration)
C) ISO 9001
D) ADA (Americans with Disabilities Act)
Answer: A) HIPAA (Health Insurance Portability and Accountability Act)
4. A CDIP identifies discrepancies between provider notes and coded
diagnoses. What is the first step they should take?
A) Delete the incorrect record
B) Notify the coding team and request clarification from the provider
C) Adjust the diagnosis without consulting anyone
D) Report the provider to HR
1
,Answer: B) Notify the coding team and request clarification from the provider
5. Which of the following best describes “documentation integrity”?
A) The process of keeping paper files in alphabetical order
B) Ensuring that documentation is accurate, complete, timely, and compliant with
regulatory standards
C) Using encryption software for EHR
D) Reducing the time spent on clinical documentation
Answer: B) Ensuring that documentation is accurate, complete, timely, and
compliant with regulatory standards
True/False Questions
6. True or False: A CDIP is responsible for auditing documentation only after the
patient is discharged.
Answer: False – A CDIP may review documentation both during patient care and
post-discharge to ensure accuracy and compliance.
7. True or False: Ensuring documentation integrity includes verifying that
abbreviations and terminology meet facility and regulatory standards.
Answer: True
8. True or False: Clinical documentation integrity is solely the responsibility of
coders, not providers or CDIPs.
Answer: False – It is a collaborative effort involving providers, coders, and CDIPs.
Scenario-Based Questions
9. Scenario: A provider documents a patient with “shortness of breath,” but the
clinical notes later indicate a diagnosis of pneumonia confirmed by chest X-ray. The
coder flags a discrepancy.
What action should a CDIP take?
A) Ignore the discrepancy since pneumonia was coded
B) Query the provider to clarify the connection between symptoms and diagnosis
C) Change the documentation to match coding without consulting the provider
D) Report the provider for negligence
Answer: B) Query the provider to clarify the connection between symptoms and
diagnosis
2
, 10. Scenario: During an audit, you notice multiple late entries in patient charts, all
signed by the same provider. What is the best practice for a CDIP?
A) Automatically reject all late entries
B) Review the late entries, confirm compliance with documentation policies, and
discuss patterns with the provider
C) Ignore the late entries
D) Require the provider to re-document all patient encounters
Answer: B) Review the late entries, confirm compliance with documentation
policies, and discuss patterns with the provider
11. Which of the following tools is most useful for a CDIP in identifying
documentation discrepancies?
A) EHR reporting and analytics tools
B) Handwritten patient schedules
C) Payroll software
D) Hospital cafeteria menu
Answer: A) EHR reporting and analytics tools
]
Multiple Choice Questions
12. Which of the following is the most important aspect when reviewing
clinical documentation for compliance?
A) Timeliness, accuracy, and completeness
B) Length of the note
C) Provider seniority
D) Number of abbreviations used
Answer: A) Timeliness, accuracy, and completeness
13. Which of the following represents a best practice for documentation
queries?
A) Queries should be leading and suggest the desired answer
B) Queries should be clear, concise, and compliant with regulatory standards
C) Queries can be informal emails without documentation
D) Queries should only be verbal
Answer: B) Queries should be clear, concise, and compliant with regulatory
standards
3
Practitioner (CDIP) exam-style questions and
answers.
CDIP Exam Questions and Answers
Multiple Choice Questions
1. What is the primary objective of the Certified Documentation Integrity
Practitioner (CDIP)?
A) To audit financial statements
B) To ensure the accuracy, consistency, and integrity of clinical documentation
C) To implement electronic health record software
D) To train medical staff on patient communication
Answer: B) To ensure the accuracy, consistency, and integrity of clinical
documentation
2. Which of the following is considered a key responsibility of a CDIP?
A) Performing surgical procedures
B) Reviewing and validating medical documentation for compliance
C) Prescribing medications
D) Managing hospital billing software
Answer: B) Reviewing and validating medical documentation for compliance
3. Which standard is most commonly referenced for documentation integrity in
healthcare?
A) HIPAA (Health Insurance Portability and Accountability Act)
B) OSHA (Occupational Safety and Health Administration)
C) ISO 9001
D) ADA (Americans with Disabilities Act)
Answer: A) HIPAA (Health Insurance Portability and Accountability Act)
4. A CDIP identifies discrepancies between provider notes and coded
diagnoses. What is the first step they should take?
A) Delete the incorrect record
B) Notify the coding team and request clarification from the provider
C) Adjust the diagnosis without consulting anyone
D) Report the provider to HR
1
,Answer: B) Notify the coding team and request clarification from the provider
5. Which of the following best describes “documentation integrity”?
A) The process of keeping paper files in alphabetical order
B) Ensuring that documentation is accurate, complete, timely, and compliant with
regulatory standards
C) Using encryption software for EHR
D) Reducing the time spent on clinical documentation
Answer: B) Ensuring that documentation is accurate, complete, timely, and
compliant with regulatory standards
True/False Questions
6. True or False: A CDIP is responsible for auditing documentation only after the
patient is discharged.
Answer: False – A CDIP may review documentation both during patient care and
post-discharge to ensure accuracy and compliance.
7. True or False: Ensuring documentation integrity includes verifying that
abbreviations and terminology meet facility and regulatory standards.
Answer: True
8. True or False: Clinical documentation integrity is solely the responsibility of
coders, not providers or CDIPs.
Answer: False – It is a collaborative effort involving providers, coders, and CDIPs.
Scenario-Based Questions
9. Scenario: A provider documents a patient with “shortness of breath,” but the
clinical notes later indicate a diagnosis of pneumonia confirmed by chest X-ray. The
coder flags a discrepancy.
What action should a CDIP take?
A) Ignore the discrepancy since pneumonia was coded
B) Query the provider to clarify the connection between symptoms and diagnosis
C) Change the documentation to match coding without consulting the provider
D) Report the provider for negligence
Answer: B) Query the provider to clarify the connection between symptoms and
diagnosis
2
, 10. Scenario: During an audit, you notice multiple late entries in patient charts, all
signed by the same provider. What is the best practice for a CDIP?
A) Automatically reject all late entries
B) Review the late entries, confirm compliance with documentation policies, and
discuss patterns with the provider
C) Ignore the late entries
D) Require the provider to re-document all patient encounters
Answer: B) Review the late entries, confirm compliance with documentation
policies, and discuss patterns with the provider
11. Which of the following tools is most useful for a CDIP in identifying
documentation discrepancies?
A) EHR reporting and analytics tools
B) Handwritten patient schedules
C) Payroll software
D) Hospital cafeteria menu
Answer: A) EHR reporting and analytics tools
]
Multiple Choice Questions
12. Which of the following is the most important aspect when reviewing
clinical documentation for compliance?
A) Timeliness, accuracy, and completeness
B) Length of the note
C) Provider seniority
D) Number of abbreviations used
Answer: A) Timeliness, accuracy, and completeness
13. Which of the following represents a best practice for documentation
queries?
A) Queries should be leading and suggest the desired answer
B) Queries should be clear, concise, and compliant with regulatory standards
C) Queries can be informal emails without documentation
D) Queries should only be verbal
Answer: B) Queries should be clear, concise, and compliant with regulatory
standards
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