CDEO Ch 1 Exam Questions With Revised
Answers
What is the central focus of clinical documentation? - answerTo facilitate optimum patient
care
The CDEO will review the findings of the auditor in order to: - answerPrevent deficient
documentation
Which sources other than federal healthcare plans...
What is the central focus of clinical documentation? - answer✔✔To facilitate optimum patient
care
The CDEO will review the findings of the auditor in order to: - answer✔✔Prevent deficient
documentation
Which sources other than federal healthcare plans may request the medical records? -
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: - answer✔✔The appropriateness of the
services provided
A provider's best defense in any legal situation is: - answer✔✔Detailed, well documented notes
To maintain an accurate medical record, what is the recommended appropriate time for provider
documentation? - answer✔✔During the encounter or as soon as possible
Quality assurance of patient care is only evident if: - answer✔✔If it is documented in the
patient's medical record
True or False: Documentation reviews can be performed on a prospective basis. -
answer✔✔True
True or False: Documentation reviews should be limited to the costliest chronic conditions to
treat. - answer✔✔False
True or False: Documentation reviews must be completed yearly. - answer✔✔False
True or False: Documentation reviews require access to the denial data. - answer✔✔False
Why is it important to involve physicians in Clinical Documentation Improvement (CDI)
programs? - answer✔✔It encourages physician participation.
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