Documentation Integrity and Data Quality Flashcards
7 cards from real CDIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation Integrity and Data Quality flashcards as text
A CDI audit reveals that a complication of care was documented and coded but the physician's note only states 'patient developed fever post-op — likely viral.' What should occur?
Answer: Query the physician to clarify whether the fever represents a complication or an unrelated condition
The physician's qualifier 'likely viral' suggests the fever may not be a complication; a query is needed to establish the clinical basis before assigning a complication code.
Which of the following is an example of a 'leading query' that violates AHIMA and ACDIS query practice guidelines?
Answer: 'Based on the lab values, does the patient have acute kidney injury?'
A leading query suggests an answer by pointing to specific clinical indicators, which can bias the physician's response and compromise documentation integrity.
When evaluating data quality, 'granularity' refers to:
Answer: The level of detail at which data is recorded
Granularity describes the level of specificity or detail captured in a data element, such as documenting 'type 2 diabetes with diabetic chronic kidney disease stage 3' rather than just 'diabetes.'
A CDI specialist is conducting a retrospective record review. Which of the following is a key difference between retrospective and concurrent review?
Answer: Retrospective review occurs after the patient has been discharged and the record is complete
Retrospective review takes place after the patient is discharged and the record is finalized, whereas concurrent review occurs while the patient is still admitted.
Which of the following best describes 'data integrity' in a health information management context?
Answer: The assurance that data is accurate, complete, consistent, and unaltered
Data integrity means that health information is trustworthy — accurate, complete, consistent, and protected from unauthorized alteration throughout its lifecycle.
A physician documents 'possible urinary tract infection' at the time of inpatient discharge. According to ICD-10-CM Official Guidelines for inpatient coding, how should this be coded?
Answer: Code the UTI as if confirmed, per inpatient uncertain diagnosis guidelines
ICD-10-CM inpatient guidelines instruct coders to code uncertain diagnoses documented at discharge (such as 'possible,' 'probable,' or 'suspected') as if confirmed.
Which tool or process is most effective for identifying systemic documentation gaps across a facility's entire inpatient population?
Answer: Real-time CDI concurrent review workflow with aggregate reporting
Concurrent CDI review with aggregate reporting identifies documentation gaps in real time across the full patient population and generates data to drive systemic improvement.