AHIMA CDIP Exam : Certified Documentation Integrity Practitioner

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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Creating policies and procedures for the query process will help eliminate

A) confusion
B) risk
C) indecision
D) duplication

2. Which of the following is considered a hospital-acquired condition if not present on admission?

A) Diabetes with hypoglycemia
B) Blood incompatibility
C) Air leak
D) Stage I and II pressure ulcers

3. The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?

A) Permit CDI practitioners to document physician responses in the charts
B) Require physicians to document responses in charts
C) Have CDI manager teaming with coding supervisor to monitor physician responses
D) Allow physician to respond via e-mail

4. A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?

A) Query physician for POA
B) Bring this case up in weekly Health Information Management meetings for further action
C) Take the case to physician advisor/champion to discuss further action
D) No query is needed

5. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for clinical significance of the CXR results.
B) Query the physician to clarify for type of COPD such as severe asthma.
C) Query the physician to clarify if CXR result means patient has pneumonia.
D) Query the physician to clarify if patient has acute COPD exacerbation.

Solutions: