A physician documents pneumonia of the Aspiration pneumonia
left lower lobe with crackles in the bases.
The patient has difficulty swallowing day 2
of admission following CVA with infarct. The
patient has a history of gastroesophageal
reflux. It would be appropriate to query for:
A. No query warranted
B. Infectious pneumonia
C. Aspiration pneumonia
D. COPD with pneumonia
Physicians queries should: Be utilized to clarify ambiguous documentation
A. Be initiated on all admissions
B. Be leading
C. Be utilized to clarify ambiguous
documentation
D. Be performed by all heath care
professionals
A CDI program should allow concurrent all of the above
documentation review to:
A. educate clinical care providers
B. allow providers to clarify hospital
acquired conditions and present on
admission indicators
C. address areas of quality impact
D. all of the above
, 11/3/24, 2:48 AM CDIP Exam 1 Domain 3 Flashcards | Quizlet
A patient has a stage III pressure ulcer Y-yes
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
The following query was found in a This is a leading query
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
appropriate
C. This is a yes or no query
D. This is an appropriate query
The following query was found in a This is an appropriate query
patient's health record. Which of the
answers best applies to this query?
Dr. Bean: The patient was admitted with
dizziness, coffee-ground emesis and
severe, burning abdominal pain. The patient
history of gastric ulcers with repeated
admissions for alcoholism and habitual use
of NSAIDS. Laboratory shows hemoglobin
of 10 with transfusion of 2 units RBC's.
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
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