Clinical Documentation Improvement Quiz

This multiple choice Clinical Documentation Improvement Quiz contains  multiple choice questions concerning CDI.

This quiz will evaluate your Clinical Documentation Improvement knowledge and point out any weaknesses. The Clinical Documentation Improvement Quiz covers the  important role of a CDI program.  CDI’s role in presenting an accurate representation of healthcare services through accurate documentation of a patient’s hospitalization is also examined.

There is one correct answer for each question and no time limit on this Clinical Documentation Improvement Quiz. Each correct answer is worth one point. Good luck, and remember that you can take the Clinical Documentation Improvement Quiz multiple times on multiple days.

Disclaimer – All answers are felt to be correct for the Clinical Documentation Improvement Quiz. This Clinical Documentation Improvement Quiz has been reviewed by HITNOTS Reviewers, and found to be of good quality.  However, if you disagree with our answer to any question, please research the issue. Mistakes happen.  A list of the HITNOTS Reviewers can be found on the HITNOTS home page by clicking here – HITNOTS.

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The correct answer to each question will appear once you have submitted your answer to each question.  You will also be able to review each individual question and your answer at the conclusion of the Clinical Documentation Improvement Quiz.  You score will appear at the end of the Clinical Documentation Improvement Quiz in the form of the number of questions that were correct, and your percentage of correct answers.

The Clinical Documentation Improvement Quiz is to be used for the purpose self instruction and learning as well as your own personal continuing education.  There are no CEUs (Continuing Education Units) available for the completion of the Clinical Documentation Improvement Quiz.

The Clinical Documentation Improvement Quiz results can be emailed to anyone by you in 3 easy steps by taking a screen shot. Please follow these instructions:  Number 1.- While viewing your score, Press Alt, while clicking Prt Scn (Print Screen). Number 2. – Then, open a word processing program, and Paste the image in to a word processing document . Save this document to your desktop. Number 3. – Compose an email, then attach the saved document. Send it to the intended recipient.

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Clinical Documentation Improvement (CDI) Basics

This quiz will evaluate your knowledge of Clinical Documentation Improvement Basics. There is one correct answer for each question and no time limit on this quiz. Each correct answer is worth one point. Good luck. Disclaimer - All answers are felt to be correct. However, if you disagree, please research the issue. Mistakes happen. Quiz results can be emailed by you in 3 easy steps by taking a screen shot. 1. While viewing your score, Press Alt, while clicking Prt Scn (Print Screen). 2. Open a word processing program, then Paste the image. Save this image to your desktop. 3. Compose an email, then attach the image. Send to the intended recipient.

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Congratulations - you have completed the HITNOTS Clinical Documentation Improvement (CDI) Basics . You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%PERCENTAGE%%. Clinical Documentation Improvement (CDI) Basics You can make a copy of your quiz result and email it to a recipient by pressing the Alt and PrtScr buttons at the same time while viewing your score. Then, paste the image into a word processing program and send it as a file attachment to the intended recepient. Clinical Documentation Improvement (CDI) Basics

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Question 1

All of the following except ____ are components of quality clinical documentation:

A	legibility
B	consistency
C	authentication
D	precision

Question 1 Explanation: 

Quality documentation should contain each of these elements - legibility, completeness, clarity, consistency and precision. Source - Managing an Effective Query Process - AHIMA

Question 2

Greg X's admission nurses note indicates that his birthdate was August 9, 1951. On the discharge summary, his birthdate was recorded as August 9, 1952. Which quality element is not evident in this medical record?

A	clarity
B	consistency
C	completeness
D	precision

Question 2 Explanation: 

Quality documentation should contain each of these elements - legibility, completeness, clarity, consistency and precision. Source - Managing an Effective Query Process - AHIMA

Question 3

This is an undesirable medical condition that negatively impacts a patient, which was not present on admission. The condition developed during a stay in a hospital. This terminology is used by Medicare and Medicaid for determining hospital reimbursement.

A	DRG
B	POA
C	HAC
D	HCC

Question 3 Explanation: 

Hospital Acquired Condition

Question 4

This is a medical classification system which approximates the likelihood of an inpatient hospital death. The categories within the system are: minor, moderate, major and extreme.

A	POA
B	HAC
C	ROM
D	SOI

Question 4 Explanation: 

Risk of Mortality

Question 5

The attending physician is responsible for which of the following types of acute care documentation?

A	Discharge summary
B	Consultation report
C	Pathology report
D	Radiology report

Question 6

Which of the following would most likely play a key role in a successful CDI program?

A	Physician Champion
B	Hospital Administrator
C	Clinical Lab Technician
D	Staff Nurse

Question 7

Documentation by the attending physician is usually present in all of the following portions of the medical record except:

A	Medication list
B	Operative Report
C	History and Physical
D	Progress Note

Question 8

This credential represents those who have proven knowledge and competence to provide guidance relative to clinical documentation in a patient’s medical record:

A	RHIT®
B	CDIP®
C	RHIA®
D	CCS®

Question 8 Explanation: 

Clinical Data Improvement Professional

Question 9

This is a system used by Medicare and Medicaid and tied to hospital reimbursement to prospectively estimate predicted costs for enrolled members during the next year of coverage.

A	HAC
B	EHR
C	PSI
D	HCC

Question 9 Explanation: 

Hierarchical Condition Categories

Question 10

The most important reason for ______ is to portray an accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures:

A	Abstracting
B	Data Analysis
C	Coding
D	CDI

Question 11

This healthcare professional would most likely act as a liaison between the CDI professional and the hospital’s medical staff:

A	Staff Nurse
B	Hospital Administrator
C	Clinical Lab Technician
D	Physician Champion

Question 12

These are metrics that can serve as a tool to help hospitals identify potentially preventable adverse events for hospital inpatients. They were developed by the Association for Healthcare Research and Quality (AHRQ).

A	POA
B	HCC
C	PSI
D	HAC

Question 12 Explanation: 

Patient Safety Indicators

Question 13

The CDI process is primarily:

A	Quantitative
B	Retrospective
C	Concurrent
D	Narrative

Question 14

Clinical documentation improvement programs which are effective can assist in providing inpatient __________.

A	RACs
B	EHR incentives
C	revenue cycle statistics
D	medical necessity

Question 15

This classification was designed to provide a basis for evaluating the use of hospital resources. It is an assessment of the acuity of a patient’s illness, based on measures like symptoms and damage to organ systems.

A	POA
B	CMI
C	SOI
D	HAC

Question 15 Explanation: 

Severity of Illness

Question 16

This is a value assigned to a group of patients in a hospital whose diagnoses and overall conditions are similar. This reflects the diversity and complexity of patients treated at the facility. The value is often used in determining the allocation of resources to care for patients in the group.

A	HAC
B	POA
C	CMI
D	ROM

Question 16 Explanation: 

Case Mix Index

Question 17

This person usually serves as a liaison between the CDI team and the medical staff:

A	chief of staff
B	hospital administrator
C	nurse administrator
D	physician advisor

Question 18

This is the condition that is determined, after study, to have caused the admission of the patient to the acute care setting and is documented by a licensed, treating physician:

A	Principal diagnosis
B	Complication
C	Secondary diagnosis
D	Comorbidity

Question 18 Explanation: 

Memorize this definition of principal diagnosis. It will serve you well in your studies.

Question 19

A successful CDI program is most likely to have the most impact on all of the following except:

A	Pay for Performance initiatives
B	Increased admissions
C	Quality measures by CMS
D	Present on Admission indicators

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