1|Page
CDIP Practice Exam 1 — 2025 Certified Documentation
Improvement Practitioner Study Guide, AHIMA Practice
Test Questions, and Exam Prep Tips
Prepare for the CDIP Practice Exam 1 (2025) with updated AHIMA-style questions, answers,
and a complete study guide. Learn key concepts in clinical documentation integrity, coding,
and compliance to pass your Certified Documentation Improvement Practitioner (CDIP)
exam on the first try.
• CDIP practice exam 1 2025
• Certified Documentation Improvement Practitioner exam
• CDIP practice test questions
• AHIMA CDIP study guide 2025
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: It was noted within the record that the patient has cellulitis of the foot. Please specify
the laterality of the patient's cellulitis.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - ANSWER-d If there is evidence of a diagnosis within the medical
record and the coder is uncertain whether it is a valid diagnosis because the documentation is
incomplete, it is the coder's responsibility to query the attending physician to determine if this
diagnosis should be included (Leon-Chisen 2013, 43-44).
,2|Page
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: It is evident within the record that the patient has a diagnosis of CKD stage V. As the
patient has a long history of diabetes and hypertension, please document this as the cause of
the CKD in this patient on dialysis.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - ANSWER-a When formulating a query, it is unacceptable to lead
a provider to document a particular response. The query should not be directing or probing and
the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42;
HHS 2014, Section I.B.16., 16).
A patient has a stage III pressure ulcer noted in the ED. While the patient is in the hospital for 6
days, the ulcer progresses to stage IV. The correct POA assignment would be:
a.Y-yes
b.N-no
c.U-unknown
d.None of the above - ANSWER-a The pressure ulcer was noted on admission. Assign "Y" for
conditions diagnosed during the admission that were clearly present but not diagnosed until
after admission occurred (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 109).
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: This patient received IV Rocephin and Vancomycin; please document severe sepsis in
the progress note to justify the drug utilization.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
,3|Page
c.This is a yes or no query
d.This is an appropriate query - ANSWER-a When formulating a query, it is unacceptable to lead
a provider to document a particular response. The query should not be directing or probing and
the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42;
HHS 2014, Section I.B.16., 16)
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: This patient was admitted with dizziness, coffee-ground emesis and severe, burning
abdominal pain. The patient has a history of gastric ulcers with repeated admissions for
alcoholism and habitual use of NSAIDS. Laboratory shows hemoglobin of 10 with transfusion of
2 units RBCs. Patient has anemia. Please document the type of anemia noted within your
progress note.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - ANSWER-d With the documented clinical indicators, it would be
appropriate to query the physician regarding the possibility of a complication resulting from
surgery. (Lovaasen and Schwerdtfeger 2011, 42; HHS 2014, Section I.B. 16., 16).
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: This patient was treated for both a primary neoplasm and a secondary neoplasm
based on documentation with the record. Was the focus of the treatment the secondary
neoplasm?
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - ANSWER-c If there is evidence of a diagnosis within the medical
record and the coder is uncertain whether it is a valid diagnosis because the documentation is
, 4|Page
incomplete, it is the coder's responsibility to query the attending physician to determine if this
diagnosis should be included (Leon-Chisen 2013, 43-44).
An inpatient undergoes a procedure and has a postoperative complication during the
hospitalization. The insurance company will not pay for the entire amount requested. Which
POA indicator is likely part of the cause?
a.N
b.Y
c.W
d.U - ANSWER-a The postoperative complication that is not present at admission. The insurance
company may not pay for the services provided to take care of the postoperative complication
(Garrett 2009, 11).
When trying to determine if documentation is present to substantiate status asthmaticus, the
coder should review the record for what terms and phrases?
a.Intractable pneumonia
b.Refractory asthma and severe, intractable wheezing
c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing - ANSWER-b Status asthmaticus is defined as continual
wheezing in spite of therapy (Leon-Chisen 2013, 230).
Within the postoperative patient, this is the most common type of shock. It occurs when large
amounts of fluids are lost from hemorrhage or severe dehydration.
a.Cardiogenic
b.Renal
c.Hypovolemic
d.Neurologic - ANSWER-c Hypovolemic shock is the most common type of shock seen in the
postoperative patient. It occurs when large amounts of fluids are lost from hemorrhage or
severe dehydration (AHA 2011, 150).
CDIP Practice Exam 1 — 2025 Certified Documentation
Improvement Practitioner Study Guide, AHIMA Practice
Test Questions, and Exam Prep Tips
Prepare for the CDIP Practice Exam 1 (2025) with updated AHIMA-style questions, answers,
and a complete study guide. Learn key concepts in clinical documentation integrity, coding,
and compliance to pass your Certified Documentation Improvement Practitioner (CDIP)
exam on the first try.
• CDIP practice exam 1 2025
• Certified Documentation Improvement Practitioner exam
• CDIP practice test questions
• AHIMA CDIP study guide 2025
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: It was noted within the record that the patient has cellulitis of the foot. Please specify
the laterality of the patient's cellulitis.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - ANSWER-d If there is evidence of a diagnosis within the medical
record and the coder is uncertain whether it is a valid diagnosis because the documentation is
incomplete, it is the coder's responsibility to query the attending physician to determine if this
diagnosis should be included (Leon-Chisen 2013, 43-44).
,2|Page
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: It is evident within the record that the patient has a diagnosis of CKD stage V. As the
patient has a long history of diabetes and hypertension, please document this as the cause of
the CKD in this patient on dialysis.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - ANSWER-a When formulating a query, it is unacceptable to lead
a provider to document a particular response. The query should not be directing or probing and
the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42;
HHS 2014, Section I.B.16., 16).
A patient has a stage III pressure ulcer noted in the ED. While the patient is in the hospital for 6
days, the ulcer progresses to stage IV. The correct POA assignment would be:
a.Y-yes
b.N-no
c.U-unknown
d.None of the above - ANSWER-a The pressure ulcer was noted on admission. Assign "Y" for
conditions diagnosed during the admission that were clearly present but not diagnosed until
after admission occurred (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 109).
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: This patient received IV Rocephin and Vancomycin; please document severe sepsis in
the progress note to justify the drug utilization.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
,3|Page
c.This is a yes or no query
d.This is an appropriate query - ANSWER-a When formulating a query, it is unacceptable to lead
a provider to document a particular response. The query should not be directing or probing and
the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42;
HHS 2014, Section I.B.16., 16)
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: This patient was admitted with dizziness, coffee-ground emesis and severe, burning
abdominal pain. The patient has a history of gastric ulcers with repeated admissions for
alcoholism and habitual use of NSAIDS. Laboratory shows hemoglobin of 10 with transfusion of
2 units RBCs. Patient has anemia. Please document the type of anemia noted within your
progress note.
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - ANSWER-d With the documented clinical indicators, it would be
appropriate to query the physician regarding the possibility of a complication resulting from
surgery. (Lovaasen and Schwerdtfeger 2011, 42; HHS 2014, Section I.B. 16., 16).
The following query was found in a patient's health record. Which of the answers best applies to
this query?
Dr. Bean: This patient was treated for both a primary neoplasm and a secondary neoplasm
based on documentation with the record. Was the focus of the treatment the secondary
neoplasm?
a.This is a leading query
b.This query brings in information not documented within the chart and is inappropriate
c.This is a yes or no query
d.This is an appropriate query - ANSWER-c If there is evidence of a diagnosis within the medical
record and the coder is uncertain whether it is a valid diagnosis because the documentation is
, 4|Page
incomplete, it is the coder's responsibility to query the attending physician to determine if this
diagnosis should be included (Leon-Chisen 2013, 43-44).
An inpatient undergoes a procedure and has a postoperative complication during the
hospitalization. The insurance company will not pay for the entire amount requested. Which
POA indicator is likely part of the cause?
a.N
b.Y
c.W
d.U - ANSWER-a The postoperative complication that is not present at admission. The insurance
company may not pay for the services provided to take care of the postoperative complication
(Garrett 2009, 11).
When trying to determine if documentation is present to substantiate status asthmaticus, the
coder should review the record for what terms and phrases?
a.Intractable pneumonia
b.Refractory asthma and severe, intractable wheezing
c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing - ANSWER-b Status asthmaticus is defined as continual
wheezing in spite of therapy (Leon-Chisen 2013, 230).
Within the postoperative patient, this is the most common type of shock. It occurs when large
amounts of fluids are lost from hemorrhage or severe dehydration.
a.Cardiogenic
b.Renal
c.Hypovolemic
d.Neurologic - ANSWER-c Hypovolemic shock is the most common type of shock seen in the
postoperative patient. It occurs when large amounts of fluids are lost from hemorrhage or
severe dehydration (AHA 2011, 150).
