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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

A) A cause-and-effect relationship between anemia and the underlying cause
B) That the blood loss was not clinically significant
C) The associated diagnosis directly on the query form
D) The associated diagnosis and the clinical rationale in the progress notes

2. An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22, and a creatinine of 1.35. The patient receives normal saline IV infusing at 100 cc/hr. The admitting diagnosis is weakness, altered mental status and dehydration. Which of the following queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?

A) Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr, please clarify the clinical significance of the lab result.
B) Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr. Is the altered mental status related to the sodium of 119?
C) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?
D) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, is this clinically significant? If so, please document a corresponding diagnosis related to this lab result.

3. Automated registration entries that generate erroneous patient identification-possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit-is an example of a potential breach of:

A) Authorship integrity
B) Patient identification and demographic accuracy
C) Documentation integrity
D) Auditing integrity

4. Which of the following can be evidence of physician-hospital alignment?

A) A high clinical documentation integrity practitioner (CDIP) query rate
B) A high physician response rate
C) A high physician agreement rate
D) A low physician agreement rate

5. A query should be generated when the documentation is

A) consistent
B) complete
C) conflicting
D) legible

Solutions: