NCLEX practice question Documentation Questions That Actually Appear in Tests

CDI Prep Questions With
Comprehensive Answers

C. Diagnostic radiologist - Correct Answer ✔️✔️Which of the following

hands-on provider's documentation should the coder not use for final coding?


A. Attending physician


B. Surgeon


C. Diagnostic radiologist


D. Interventional cardiologis


B. Nurses - Correct Answer ✔️✔️Which practitioners, along with coding

professionals, are proficient at picking up deficiencies in clinical documentation

yet must focus on giving care?


A. Mid-level practitioners


B. Nurses


C. Surgeons


D. Consultants

,D. Outpatient - Correct Answer ✔️✔️Which healthcare setting requires

high levels of proactivity from management and clinical teams to ensure accurate

and timely clinical documentation?


A. Physical therapy


B. Emergency department


C. Inpatient


D. Outpatient


A. Emergency department - Correct Answer ✔️✔️Which of the below items

is not an inpatient healthcare setting?


A. Emergency department


B. Rehabilitation facilities


C. Skilled Nursing facilities


C. Sub Acute facilities


C. Gold standard - Correct Answer ✔️✔️High-quality clinical documentation

is the basis for what standard?


A. The Joint Commission

, B. Clinical documentation improvement standard


C. Gold standard


D. AHIMA regulatory standard


C. Coding - Correct Answer ✔️✔️What allows the diagnostic, treatment,

and response of information of the patient to be aggregated into a uniform data

set?


A. Physician documentation


B. Transcription


C. Coding


D. Clinical documentation improvement


D. Impression and plan - Correct Answer ✔️✔️What part of the health

record, usually located at the end the document, provides a complete picture of

the patient's diagnosis?


A. History and physical


B. Consultation reports


C. Assessment and exam