CDIP Domain 3 Record Review & Document Clarification 2023 updated to pass

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