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Which subsequent documentation in the health record suggests the provider did not understand the query?
A patient's progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the...
Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?
Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?A . Inconsistent clinically relevant queriesB . CDI practitioners sending multiple queries to hospitalist physiciansC . The physician advisor/champion's interventions with noncompliant physiciansD . Providing many lectures, newsletters, tip sheets, and pocket cards for...
A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side.
A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default...
A query should be generated when documentation contains a
A query should be generated when documentation contains aA . postoperative hospital-acquired conditionB . principal diagnosis without an MCCC . diagnosis without clinical validationD . problem list with symptoms related to the chief complaintView AnswerAnswer: C Explanation: A query should be generated when documentation contains a diagnosis without clinical validation,...
Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?
Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?A . Manager of Surgical ServicesB . Director of InformaticsC . Manager of HIM/CodingD . Director of Risk ManagementView AnswerAnswer: C Explanation: The manager of HIM/Coding should...
Which of the following is an example of a hospital-acquired condition when not present on admission?
Which of the following is an example of a hospital-acquired condition when not present on admission? A. Iatrogenic pneumothorax with lung biopsy B. Iatrogenic pneumothorax with venous catheterization C. Pressure ulcer stage II D. Pressure ulcer stage IIIView AnswerAnswer: D Explanation: A hospital-acquired condition (HAC) is an undesirable situation or...
A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is
A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant...
A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to
A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is toA . query the provider to see if acute on chronic respiratory failure is supported by the...
incomplete records for failure to respond to queries?
When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?A . AdmittingB . ConsultingC . SurgicalD . CredentialingView AnswerAnswer: A Explanation: When queries are part of...
What would the appropriate action be?
Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?A . No query is needed because the patient was dehydratedB ....
