Clinical document Improvement (321)
Exam Questions and Answers
Clinical documentation improvement (CDI) - Answer-Process to facilitate the accurate
representation of a patient’s clinical status n the patient health record
CDI Goals - Answer-1. Initiate concurrent and as appropriate retrospective reviews of
health records for conflicting, incomplete, or no specific provider information
2. Key organizational stakeholdes are involved in setting additional program goals
Operational considerations - Answer-1. composition
2.alignment of the CDI prog
3.budget
4.frequent chart reviews
Interdisciplinary Teams - Answer-1. Single Discipline Model
2. Hybrid staffing model
Single Discipline model - Answer-CDI team composed only of one professions such as
physicians, nurses, HIM/coding professionals
Hybrid staffing model - Answer-Mix of professionals with a experience related to
documentation such as physicians, nurses, HIM Professionals, quality improvement,
utilization review/management, organizations training
Physician champion aka - Answer-Physician advisor
The most accurate and specific documentation possible is then transferred into what -
Answer-Coded data
(CDIP) Clinical Documentation Improvement Professional Certification - Answer-Was
developed by AHIMAs Commission on Certification for Health Informatics and
information Management
CDI program May be housed where - Answer--HIM program
-Corporate Compliance
-quality improvement
-other area depending on organizational need
Staff who have passed CDIP exam indicate that they are - Answer-1. Knowledgeable
and competent on clinical info
2. Able to demonstrate competency in capturing documentation necessary to
communicate patients health status and condition
Exam Questions and Answers
Clinical documentation improvement (CDI) - Answer-Process to facilitate the accurate
representation of a patient’s clinical status n the patient health record
CDI Goals - Answer-1. Initiate concurrent and as appropriate retrospective reviews of
health records for conflicting, incomplete, or no specific provider information
2. Key organizational stakeholdes are involved in setting additional program goals
Operational considerations - Answer-1. composition
2.alignment of the CDI prog
3.budget
4.frequent chart reviews
Interdisciplinary Teams - Answer-1. Single Discipline Model
2. Hybrid staffing model
Single Discipline model - Answer-CDI team composed only of one professions such as
physicians, nurses, HIM/coding professionals
Hybrid staffing model - Answer-Mix of professionals with a experience related to
documentation such as physicians, nurses, HIM Professionals, quality improvement,
utilization review/management, organizations training
Physician champion aka - Answer-Physician advisor
The most accurate and specific documentation possible is then transferred into what -
Answer-Coded data
(CDIP) Clinical Documentation Improvement Professional Certification - Answer-Was
developed by AHIMAs Commission on Certification for Health Informatics and
information Management
CDI program May be housed where - Answer--HIM program
-Corporate Compliance
-quality improvement
-other area depending on organizational need
Staff who have passed CDIP exam indicate that they are - Answer-1. Knowledgeable
and competent on clinical info
2. Able to demonstrate competency in capturing documentation necessary to
communicate patients health status and condition
