Clinical Documentation Improvement

Question 1

This is documentation that is detailed and has the maximum content. This means that the physician has fully addressed all concerns in the patient record.

For example: if the patient has blood drawn and the results show low sodium and the patient is started on sodium tablets but the documen­tation only states low sodium, there is not a diagnosis to support the clinical abnormality and treatment plan. A query may be needed to determine if a diagnosis can be provided.

Answer 1

Complete

Question 2

This is documentation that does not contradict itself.

An example would be having con­flicting diagnoses, such as one provider note stating the patient has chronic diastolic heart failure and the next note stating the patient has chronic systolic heart failure. In this scenario a query may be needed to determine the type of heart failure.

Answer 2

Consistent

Question 3

This is documentation that is prepared, signed, and dated by the provider at the time the care was provided.

An example is a note in which the content may have all the characteristics of high-quality docu­mentation, but it was never signed or dated by the physician. A query may be needed to request a signature and date.

Answer 3

Timely

Question 4

This is documentation that thoroughly describes what is occurring with the patient.

Answer 4

Clear

Question 5

This is documentation that is clearly defined by including the highest level of specificity that can be determine from the clinical evidence.

An example of precision is documenting the specific type of gastroenteritis, such as infectious or non-infectious gastroenteritis. If infectious, the organism would also need to be documented if known.

Answer 5

Precise

Question 6

This documentation that is clear enough for the reader to easily interpret. If the documentation cannot be interpreted, then a query may be needed.

Answer 6

Legible

Question 7

This is trustworthy documentation.

For example, if a stage 4 chronic kidney disease (CKD) patient is started on Epogen, the stage 4 CKD is not a trustworthy diagnosis to support the treatment of Epogen. This is because the Epogen is not used to treat stage 4 CKD, but most likely prescribed to treating an associated anemia. In this example a query may be needed to identify the diagnosis being treated to ensure the documentation is trustworthy.

Answer 7

Reliable

Question 8

______ reviews usually occur on patient care units or in outpatient clinics, or they can be conducted remotely via the electronic health record (EHR).

Answer 8

CDI

Question 9

What is the method of clarification used by the CDI professional?

Answer 9

Written
Verbal
Electronic

Question 10

Depending on the structure and design of the CDI program, the program may be staffed entirely by HIM coding professionals, entirely by nurses, or a combination of both.

In some programs there may be dedicated provider liaisons or provider champions who conduct reviews and communicate with other providers on documentation issues. And in other organizations, the CDI program may have staff who come from several professions and work together in daily collaboration.

Answer 10

CDI Staffing