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Exam (elaborations)

CDIP Exam Question and Answer with Complete Solutions

  • Course
  • CDIP
  • Institution
  • CDIP

CDIP Exam Question and Answer with Complete Solutions What is a reason a physician documentation can be difficult to review? - Illegible handwriting The best scientific data available for clinical documentation is also known as - Evidence-based medicine The two-part theory for high-quality cl...

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  • October 25, 2024
  • 23
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • CDIP
  • CDIP
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JOSHCLAY
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
CDI Exam Question and Answer with

Complete Solutions


What is a reason a physician documentation can be difficult to review? -

✔✔Illegible handwriting

The best scientific data available for clinical documentation is also known

as - ✔✔Evidence-based medicine

The two-part theory for high-quality clinical documentation is a cause-and-

effect theory that is derived from which two sources? - ✔✔Legal/Regulatory

Sources and Peer-Reviewed Research

When discussing completeness in a health record, the physician has fully

addressed all concerns, as well as what other authentication? -

✔✔Signature and date

Peer-reviewed academic literature states that this factor shows a

relationship to quality of care as well as support for concurrent CDI

programs: - ✔✔Documentation

What evidence supports the lack of high-quality clinical documentation in

the medical field? - ✔✔CDI is not taught in medical school

,©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
Which item is not recommended by the HHS and the OIG for minimum

compliance with clinical documentation regulations? - ✔✔Physicians

should include vaccination records

What does "reliable" in high-quality clinical documentation mean? -

✔✔Physician documentation supports medical treatment

Which item is an important aspect of consistent high-quality clinical

documentation? - ✔✔Creates a clear picture for subsequent reviewers of

documentation

Which aspect of the discharge summary is the biggest challenge to house

staff, mid-level practitioners, and attending physicians as they compose the

patient's discharge summary? - ✔✔Timeliness

Which aspect of the patient's health record can a member of the house

staff or midlevel practitioner create, yet ultimately needs the attending

physician to confirm accuracy? - ✔✔Problem list

Interns, residents, and fellows are physicians with lesser accountability due

to their inability to act as an attending physician and are also known as

______. - ✔✔House staff

, ©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
Which two medical professionals serve as mid-level practitioners by

supporting physicians in the delivery of care? - ✔✔Nurse practitioners and

physician assistants

In 1982, which aspect of medical billing/reimbursement increased the

demand for accuracy and timeliness with regard to medical coding? -

✔✔Reimbursement was driven by codes assigned to patient care

Which hands-on provider's documentation should the coder not use for

final coding? - ✔✔Diagnostic radiologist

Which practitioners, along with coding professionals, are proficient at

picking up deficiencies in clinical documentation yet must focus on giving

care? - ✔✔Nurses

Which healthcare setting requires high levels of proactivity from

management and clinical teams to ensure accurate and timely clinical

documentation? - ✔✔Outpatient

Which item is not an inpatient healthcare setting? - ✔✔Emergency

department

High-quality clinical documentation is the basis for what standard? -

✔✔Gold standard

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