CDI Prep questions with correct answers

B. Illegible handwriting CORRECT ANSWER Which of the following is a reason physician documentation can be difficult to review? A. High volume of pages B. Illegible handwriting C. Typographical errors D. Deficiencies A. Evidence-Based Medicine CORRECT ANSWER The best scientific data available for clinical documentation is also known as A. Evidence-Based Medicine B. Medical Necessity C. Best-of-Practice D. Gold Standard A. Legal/Regulatory Sources and Peer-Reviewed Research CORRECT ANSWER The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is derived from which two sources? A. Legal/Regulatory Sources and Peer-Reviewed Research B. American Health Information Management Association and the Joint Commission C. Centers for Medicare/Medicaid Services (CMS) and the Department of Health and Human Services (HHS) D. OIG and CMS A. Signature and date CORRECT ANSWER When discussing completeness in a health record, the physician has fully addressed all concerns, as well as what other authentication? A. Signature and date B. Nurses signature and date C. Initials and date D. Signature Stamp