CDI Question and Answer Key | WITH FULL SOLUTION

CDI Question and Answer Key | WITH FULL SOLUTION What is a reason a physician documentation can be difficult to review? - Illegible handwriting The best scientific data available for clinical documentation is also known as - Evidence-based medicine The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is derived from which two sources? - Legal/Regulatory Sources and Peer-Reviewed Research When discussing completeness in a health record, the physician has fully addressed all concerns, as well as what other authentication? - Signature and date Peer-reviewed academic literature states that this factor shows a relationship to quality of care as well as support for concurrent CDI programs: - Documentation What evidence supports the lack of high-quality clinical documentation in the medical field? - CDI is not taught in medical school Which item is not recommended by the HHS and the OIG for minimum compliance with clinical documentation regulations? - Physicians should include vaccination records What does "reliable" in high-quality clinical documentation mean? - Physician documentation supports medical treatment Which item is an important aspect of consistent high-quality clinical documentation? - Creates a clear picture for subsequent reviewers of documentation Which aspect of the discharge summary is the biggest challenge to house staff, mid-level practitioners, and attending physicians as they compose the patient's discharge summary? - Timeliness Which aspect of the patient's health record can a member of the house staff or midlevel practitioner create, yet ultimately needs the attending physician to confirm accuracy? - Problem list Interns, residents, and fellows are physicians with lesser accountability due to their inability to act as an attending physician and are also known as ______. - House staff Which two medical professionals serve as mid-level practitioners by supporting physicians in the delivery of care? - Nurse practitioners and physician assistants In 1982, which aspect of medical billing/reimbursement increased the demand for accuracy and timeliness with regard to medical coding? - Reimbursement was driven by codes assigned to patient care Which hands-on provider's documentation should the coder not use for final coding? - Diagnostic radiologist Which practitioners, along with coding professionals, are proficient at picking up deficiencies in clinical documentation yet must focus on giving care? - Nurses Which healthcare setting requires high levels of proactivity from management and clinical teams to ensure accurate and timely clinical documentation? - Outpatient Which item is not an inpatient healthcare setting? - Emergency department High-quality clinical documentation is the basis for what standard? - Gold standard What allows the diagnostic, treatment, and response of information of the patient to be aggregated into a uniform data set? - Coding What part of the health record, usually located at the end the document, provides a complete picture of the p