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Certified Documentation Integrity Practitioner Questions 16–20 (page: 5)

A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for pseudomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would:

Whether or not queries should be kept as a permanent part of the medical record is decided by

A patient was admitted due to possible pneumonia Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.
Discharge diagnoses:
1. Pneumonia
2. COPD
3. Current smoker
What is the correct diagnostic related group assignment?

The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to

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