CDI Question and Answer Key-2024 Exam Update!!
What is a reason a physician documentation can be difficult to review? - Correct Answer
Illegible handwriting
The best scientific data available for clinical documentation is also known as - Correct
Answer 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? - Correct Answer 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? - Correct Answer 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: - Correct Answer Documentation
What evidence supports the lack of high-quality clinical documentation in the medical
field? - Correct Answer 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? - Correct Answer Physicians should include
vaccination records
What does "reliable" in high-quality clinical documentation mean? - Correct Answer
Physician documentation supports medical treatment
Which item is an important aspect of consistent high-quality clinical documentation? -
Correct Answer 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? - Correct Answer 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? -
Correct Answer 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 ______. - Correct Answer
House staff
Which two medical professionals serve as mid-level practitioners by supporting physicians
in the delivery of care? - Correct Answer 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? - Correct Answer Reimbursement
was driven by codes assigned to patient care
Which hands-on provider's documentation should the coder not use for final coding? -
Correct Answer Diagnostic radiologist
Which practitioners, along with coding professionals, are proficient at picking up
deficiencies in clinical documentation yet must focus on giving care? - Correct Answer
Nurses
Which healthcare setting requires high levels of proactivity from management and clinical
teams to ensure accurate and timely clinical documentation? - Correct Answer Outpatient
Which item is not an inpatient healthcare setting? - Correct Answer Emergency
department
High-quality clinical documentation is the basis for what standard? - Correct Answer Gold
standard
What allows the diagnostic, treatment, and response of information of the patient to be
aggregated into a uniform data set? - Correct Answer Coding
What part of the health record, usually located at the end the document, provides a
complete picture of the patient's diagnosis? - Correct Answer Impression and plan
What is a reason a physician documentation can be difficult to review? - Correct Answer
Illegible handwriting
The best scientific data available for clinical documentation is also known as - Correct
Answer 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? - Correct Answer 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? - Correct Answer 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: - Correct Answer Documentation
What evidence supports the lack of high-quality clinical documentation in the medical
field? - Correct Answer 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? - Correct Answer Physicians should include
vaccination records
What does "reliable" in high-quality clinical documentation mean? - Correct Answer
Physician documentation supports medical treatment
Which item is an important aspect of consistent high-quality clinical documentation? -
Correct Answer 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? - Correct Answer 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? -
Correct Answer 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 ______. - Correct Answer
House staff
Which two medical professionals serve as mid-level practitioners by supporting physicians
in the delivery of care? - Correct Answer 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? - Correct Answer Reimbursement
was driven by codes assigned to patient care
Which hands-on provider's documentation should the coder not use for final coding? -
Correct Answer Diagnostic radiologist
Which practitioners, along with coding professionals, are proficient at picking up
deficiencies in clinical documentation yet must focus on giving care? - Correct Answer
Nurses
Which healthcare setting requires high levels of proactivity from management and clinical
teams to ensure accurate and timely clinical documentation? - Correct Answer Outpatient
Which item is not an inpatient healthcare setting? - Correct Answer Emergency
department
High-quality clinical documentation is the basis for what standard? - Correct Answer Gold
standard
What allows the diagnostic, treatment, and response of information of the patient to be
aggregated into a uniform data set? - Correct Answer Coding
What part of the health record, usually located at the end the document, provides a
complete picture of the patient's diagnosis? - Correct Answer Impression and plan
