CDIP Study Guide
Patients with more medications or vascular lines, and longer lengths of
stay, were significantly more likely to have higher rates of documentation
errors. T/F?
True
When should a provider provide documentation for the best quality of
documentation?
Right after caring for a patient
What type of health record documentation should be top priority when
undertaking a CDI program?
Inpatient Acute Care Health Record Documentation
What are the key activities of a CDI program? (2)
Concurrent review and concurrent physician inquiry
What is a common function that has created a problem for data integrity
of the health record that healthcare organizations should establish
compliance guidance and well thought-out processes on?
Copy and Paste
When should a medical history and physical examination be completed?
- No more than 30 days before or 24 hours after admission or
registration
- Prior to surgery or procedure requiring anesthesia services
In what timeframe should a final diagnosis of a health record and a
discharge summary be placed according to CMS conditions of
participation?
Within 30 days following discharge
,Who does OIG used to administer Medicare A and B as well as to
process claims for services rendered?
Medicare Administrative Contractors (MACs)
What is important about ventilation in the medical record?
The timeframe of ventilation.
What is a common type of malnutrition that the OIG has identified as an
over-used diagnosis resulting in overpayment under the MS-DRG
system?
Kwashiorkor Malnutrition
Four standards used in EBM (Evidence Based Medicine)
Design
Terminology
Performance
Procedural
7 Quality Clinical Documentation Criteria
Legible
Reliable
Precise
Complete
Consistent
Clear
Timely
Make sure to be able to identify examples of these*
Each clinical criteria in a patient's health record must meet what?
ALL seven of the criteria (gold standard) for clinical documentation
, What might be required if a discharge summary is inconsistent with other
entries in the health record?
A query
What does the 2014 ICD-10-PCS guidelines state is essential to achieve
complete and accurate documentation?
A joint effort between the healthcare provider and the coder
When there is provider disagreement on a diagnosis in the record or the
diagnosis is unclear coders must always?
Submit a query to clarify
Which physicians documentation is used for coding if two providers
cannot agree?
The attending physician's documentation
What all is required in an Emergency Department Record?
The ED record must include the time, means of arrival, immediate care
and treatment notes, final disposition, condition at discharge, and
instructions for follow-up.
Often the physician copies the entire__________and pastes it into the
discharge summary, giving the appearance that all the diagnoses on the
list are pertinent to the current admission.
Problem List
The purpose and scope of the problem list in all healthcare settings
(inpatient, outpatient facility, and physician practice) should:
- Facilitate continuity of care between patient visits
Patients with more medications or vascular lines, and longer lengths of
stay, were significantly more likely to have higher rates of documentation
errors. T/F?
True
When should a provider provide documentation for the best quality of
documentation?
Right after caring for a patient
What type of health record documentation should be top priority when
undertaking a CDI program?
Inpatient Acute Care Health Record Documentation
What are the key activities of a CDI program? (2)
Concurrent review and concurrent physician inquiry
What is a common function that has created a problem for data integrity
of the health record that healthcare organizations should establish
compliance guidance and well thought-out processes on?
Copy and Paste
When should a medical history and physical examination be completed?
- No more than 30 days before or 24 hours after admission or
registration
- Prior to surgery or procedure requiring anesthesia services
In what timeframe should a final diagnosis of a health record and a
discharge summary be placed according to CMS conditions of
participation?
Within 30 days following discharge
,Who does OIG used to administer Medicare A and B as well as to
process claims for services rendered?
Medicare Administrative Contractors (MACs)
What is important about ventilation in the medical record?
The timeframe of ventilation.
What is a common type of malnutrition that the OIG has identified as an
over-used diagnosis resulting in overpayment under the MS-DRG
system?
Kwashiorkor Malnutrition
Four standards used in EBM (Evidence Based Medicine)
Design
Terminology
Performance
Procedural
7 Quality Clinical Documentation Criteria
Legible
Reliable
Precise
Complete
Consistent
Clear
Timely
Make sure to be able to identify examples of these*
Each clinical criteria in a patient's health record must meet what?
ALL seven of the criteria (gold standard) for clinical documentation
, What might be required if a discharge summary is inconsistent with other
entries in the health record?
A query
What does the 2014 ICD-10-PCS guidelines state is essential to achieve
complete and accurate documentation?
A joint effort between the healthcare provider and the coder
When there is provider disagreement on a diagnosis in the record or the
diagnosis is unclear coders must always?
Submit a query to clarify
Which physicians documentation is used for coding if two providers
cannot agree?
The attending physician's documentation
What all is required in an Emergency Department Record?
The ED record must include the time, means of arrival, immediate care
and treatment notes, final disposition, condition at discharge, and
instructions for follow-up.
Often the physician copies the entire__________and pastes it into the
discharge summary, giving the appearance that all the diagnoses on the
list are pertinent to the current admission.
Problem List
The purpose and scope of the problem list in all healthcare settings
(inpatient, outpatient facility, and physician practice) should:
- Facilitate continuity of care between patient visits
