Updated: Jun 07, 2026
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1. A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?
A) Percent of insurance billings denied due to lack of record documentation
B) Number of coder queries regarding inconsistent physician record documentation
C) Results of a survey of physicians that asks about documentation practices
D) Incidence of redundancies in physician notes in a sample of hospital admissions
2. After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?
A) Expand the CDI program to larger areas in outpatient clinics
B) Identify key metrics to develop program measures for coders
C) Establish a CDI steering committee to build a strong foundation
D) Prioritize to focus on efforts with the largest return on investment
3. A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?
A) The Merck Manual
B) Physician's Desk Reference
C) Medical Dictionary
D) AMA CPT Assistant
4. The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to
A) identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
B) determine if only the treatment is documented and there is no diagnosis documented
C) look for documented conditions that have well supported accompanying clinical criteria
D) watch for reportable conditions or conditions that are unambiguous or otherwise complete
5. Which of the following is considered a hospital-acquired condition if not present on admission?
A) Diabetes with hypoglycemia
B) Air leak
C) Blood incompatibility
D) Stage I and II pressure ulcers
Solutions:
| Question # 1 Answer: D | Question # 2 Answer: C | Question # 3 Answer: A | Question # 4 Answer: B | Question # 5 Answer: C |
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