CDEO CHAPTER 1 UPDATED 2024-2025
/QUESTIONS WITH COMPLETE SOLUTIONS
(A+)
Name a documentation deficiency that has a negative impact on
patient outcomes. Correct Answer Failure to include the
instructions for post procedure care and potential complications.
What is an effective method for communicating documentation
deficiencies to a provider? Correct Answer Provide examples of
the provider's documentation deficiencies with suggestions for
improvement.
What are 3 things considered to be a purpose of documentation
improvement programs? Correct Answer Improve patient
outcomes.
Prepare physicians to provide documentation that supports quality
measures.
Improve the provider query process.
How can an effective CDI program improve patient outcomes?
Correct Answer Provide a detailed record of the care provided to
the patient.
What is a recommendation that should be made to providers
regarding the patient's problem list? Correct Answer Significant
changes should be documented at each encounter.
Failure to document which of the following could lead to a
negative patient outcome?
Allergies: PCN
Patient denies loss of appetite or vomiting.
Patient has remained on her diet.
, Patient indicates her daughter lives with her to assist in her care.
Correct Answer Allergies: PCN
What is the central focus of clinical documentation? Correct
Answer To facilitate optimum patient care
The CDEO will review the findings of the auditor in order to:
Correct Answer Prevent deficient documentation
Which sources other than federal healthcare plans may request
the medical records? Correct Answer Patients, Providers
involved with the patient's care, Employers for worker's
compensation claims, Private Payers
In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely
what services were actually provided. Other than the site of
service the medical record may be used to validate: Correct
Answer The appropriateness of the services provided
A provider's best defense in any legal situation is: Correct Answer
Detailed, well documented notes
To maintain an accurate medical record, what is the
recommended appropriate time for provider documentation?
Correct Answer During the encounter or as soon as possible
Quality assurance of patient care is only evident if: Correct
Answer If it is documented in the patient's medical record
True or False: Documentation reviews can be performed on a
prospective basis. Correct Answer True
/QUESTIONS WITH COMPLETE SOLUTIONS
(A+)
Name a documentation deficiency that has a negative impact on
patient outcomes. Correct Answer Failure to include the
instructions for post procedure care and potential complications.
What is an effective method for communicating documentation
deficiencies to a provider? Correct Answer Provide examples of
the provider's documentation deficiencies with suggestions for
improvement.
What are 3 things considered to be a purpose of documentation
improvement programs? Correct Answer Improve patient
outcomes.
Prepare physicians to provide documentation that supports quality
measures.
Improve the provider query process.
How can an effective CDI program improve patient outcomes?
Correct Answer Provide a detailed record of the care provided to
the patient.
What is a recommendation that should be made to providers
regarding the patient's problem list? Correct Answer Significant
changes should be documented at each encounter.
Failure to document which of the following could lead to a
negative patient outcome?
Allergies: PCN
Patient denies loss of appetite or vomiting.
Patient has remained on her diet.
, Patient indicates her daughter lives with her to assist in her care.
Correct Answer Allergies: PCN
What is the central focus of clinical documentation? Correct
Answer To facilitate optimum patient care
The CDEO will review the findings of the auditor in order to:
Correct Answer Prevent deficient documentation
Which sources other than federal healthcare plans may request
the medical records? Correct Answer Patients, Providers
involved with the patient's care, Employers for worker's
compensation claims, Private Payers
In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely
what services were actually provided. Other than the site of
service the medical record may be used to validate: Correct
Answer The appropriateness of the services provided
A provider's best defense in any legal situation is: Correct Answer
Detailed, well documented notes
To maintain an accurate medical record, what is the
recommended appropriate time for provider documentation?
Correct Answer During the encounter or as soon as possible
Quality assurance of patient care is only evident if: Correct
Answer If it is documented in the patient's medical record
True or False: Documentation reviews can be performed on a
prospective basis. Correct Answer True
