CDIP Domain 3: Record Review &
Document Clarification Exam Questions
with Correct Answers
POA -Answer- Present on admission
Concurrent reviews -Answer- CDI specialist reviews the patient record while the
patient is in the hospital
Ethical -Answer- Conforming to accepted standards of conduct
Ethical Queries -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? -Answer- Attending physician
Legible -Answer- the record is clear enough for the reader to comprehend and easily
decipher
Reliable -Answer- the content of the record is trustworthy, safe, and yielding the same
result when repeated
Precise -Answer- the record is accurate, exact, and strictly defined
Complete -Answer- the record has the maximum content and is thorough
Consistent -Answer- the record is not contradictory
Clear -Answer- the documentation thoroughly describes what is happening with the
patient
Timely -Answer- the record is prepared by the provider at the point it is needed by
clinicians for patient care
HAC -Answer- Hospital Acquired Condition
SOI -Answer- Severity of Illness
ROM -Answer- Risk of Mortality
Hospital Acquired Conditions -Answer- conditions that will not be reimbursed if they
occur in the hospital after admission
Document Clarification Exam Questions
with Correct Answers
POA -Answer- Present on admission
Concurrent reviews -Answer- CDI specialist reviews the patient record while the
patient is in the hospital
Ethical -Answer- Conforming to accepted standards of conduct
Ethical Queries -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? -Answer- Attending physician
Legible -Answer- the record is clear enough for the reader to comprehend and easily
decipher
Reliable -Answer- the content of the record is trustworthy, safe, and yielding the same
result when repeated
Precise -Answer- the record is accurate, exact, and strictly defined
Complete -Answer- the record has the maximum content and is thorough
Consistent -Answer- the record is not contradictory
Clear -Answer- the documentation thoroughly describes what is happening with the
patient
Timely -Answer- the record is prepared by the provider at the point it is needed by
clinicians for patient care
HAC -Answer- Hospital Acquired Condition
SOI -Answer- Severity of Illness
ROM -Answer- Risk of Mortality
Hospital Acquired Conditions -Answer- conditions that will not be reimbursed if they
occur in the hospital after admission
