Cdip practice real - Study guides, Class notes & Summaries

In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a.Note the condition as present on admission b.Query the physician to determine if the condition was present on admission...

In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a.Note the condition as present on admission b.Query the physician to determine if the condition was present on admission...

In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a.Note the condition as present on admission b.Query the physician to determine if the condition was present on admission...

A patient presents with a myocardial infarction (MI) and intervention was carried out. It was noted the patient does have coronary artery disease (CAD). The consulting physician has stated to staff the CAD should be sequenced first. What should be the principal diagnosis? a. CAD b.MI c. Chest pain d. Ill-defined condition - ANSEWRS-b No, the consultant's advice is not correct. Sequence the AMI as the principal diagnosis since it is the acute condition and the reason for the admission. You sh...

CDIP PRACTICE REAL EXAM 1 WITH 100%GUARANTEED SUCCESS NEW UPDATE!!!! In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a.Note the condition as present on admiss...

CDIP PRACTICE REAL EXAM 2 WITH 100%VERIFIED QUESTIONS AND ANSWERS LATEST UPDATE!!! A patient presents with a myocardial infarction (MI) and intervention was carried out. It was noted the patient does have coronary artery disease (CAD). The consulting physician has stated to staff the CAD should be sequenced first. What should be the principal diagnosis? a.CAD b.MI c.Chest pain d.Ill-defined condition - ANSEWRS-b No, the consultant's advice is not correct. Sequence the AMI as th...

In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a.Note the condition as present on admission b.Query the physician to determine if the condition was present on admission...

out. It was noted the patient does have coronary artery disease (CAD). The consulting physician has stated to staff the CAD should be sequenced first. What should be the principal diagnosis? a. CAD b.MI c. Chest pain d. Ill-defined condition - ANSEWRS-b No, the consultant's advice is not correct. Sequence the AMI as the principal diagnosis since it is the acute condition and the reason for the admission. You should continue to follow correct coding and reporting practices and report the AMI ...

CDIP LATEST 2023 GRADED A+ eMAR Electronic medication administration record PACS Picture archive and communication system CPOE Computerized provider/practitioner/physician order entry CAMP Coaching, asking, mastering, peer learning ICEHR Integrated care EHR HCO Health care organization HIM Health Information Management Stage 0 EHR implementation Lowest level of transformation Stage 1 EHR implementation Electronic capture of health info is in standardized format, track key clinical condit...