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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?

A) Legible
B) Complete
C) Precise
D) Reliable

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

3. A noncompliant query includes querying the provider regarding

A) acute blood loss anemia due to low hemoglobin treated with iron supplements
B) sepsis that was present on admission because sepsis was only documented in the discharge summary
C) morbid obesity due to BMI of 40.9 documented on the history and physical
D) gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators

4. 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) query the provider to see if chronic respiratory failure is supported by the health record
B) query the provider to see if acute on chronic respiratory failure is supported by the health record
C) query the provider to see if respiratory insufficiency is supported by the health record
D) code the diagnoses of COPD exacerbation and chronic respiratory failure

5. Which of the following should be examined when developing documentation integrity projects?

A) Physician satisfaction surveys
B) CC and MCC capture rates
C) Query rates from coding staff
D) Coding productivity statistics

Solutions: