CDIP | 65 Questions and Answers(A+ Solution guide)

CDI program data includes: - 1. All cases that were reviewed 2. Number of cases with queries 3. Nature of the query 4. Physician response to the query Queries should only be asked: - 1. If there is clinical evidence that the documentation is imcomplete or does not meet one of the seven criteria for high-quality clinical documentation. 2. By an individual with solid clinical knowledge. 3. In an open-ended manner (no yes or no questions) 4. In a nonleading manner. 5. To the individual whose documentaion is in question or who is responible for interpreting test results or other data in the patient's record. Query process and procedure should address: - 1. When queries will be asked. 2. Who will ask queries and to whom queries will be asked. 3. The hospital's responsibility in supporting the quering process. 4. The physician's responsibility in responding to queries. 5. Acceptable ways to responding to queries. Examples of when a query is required may include: - 1. Documentation of reportable conditions or procedures is conflicting, ambigious, or is otherwise incomplete. 2. Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or higher specificity of an already documented condition. 3. The patient is receiving treatment for a condition that has not been documented. 4. Abnormal operative or procedureal findings are not documented. 5. It is unclear as to whether a condition was ruled out. 6. The pricipal diagnosis is not clearly identified.Septicemia - A systemic disease with the presence and persistence of pathogenic micro-organisms or toxins in the blood. No longer considered synonymous with sepsis. Sepsis - Sepsis is SIRS due to an infection . Infection can originate anywhere in the body and be triggered by a bacterial, viral, parasitic, or fungal infection. Severe Sepsis - SIRS due to infection with organ dysfunction. Sepsis associated with acute dysfunction in one or more organs. Organ dysfunction bay be cardiovascular, renal, respiratory, hepatic, hematological, central nervous system, or metabolic acidosis. SIRS - SIRS is the systemic response to infection or trauma. The systemic response is manifested by a variety of clinical signs and symptoms such as: Fever (>100.4 degrees F), Hypothermia (<96.8 degrees F), WBC >= to 12000 cellsmm3 (leukocytosis), WBC <= to 4000 cells/mm3 or 10% immature cells, heart reat >90 bpm, respirations >20 breaths/minute or PcCO2 <32 mg of mercury, hypotension, altered mental status. Septic Shock - Sepsis with hypotension or a failure of the cardiovascular system. Endotoxic shock and gram negative shock are synomymous with septic shock, septic shock = severe sepsis Bacteremia - Bacteria in the blood without an associated inflammatory response. Denotes laboratory findings of viable bateria in the blood with no systemic manifestations. Progresses to septicemia only when there is a more severe infections process or an impaired immune system