QUESTION: 17

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

federal law
physician preference
state law
organizational policy

Answer(s): D

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?

DRG 190 Chronic Obstructive Pulmonary Disease with MCC
DRG 204 Respiratory Signs and Symptoms
DRG 194 Simple Pneumonia and Pleurisy without CC/MCC
DRG 202 Bronchitis and Asthma with CC-MCC

Answer(s): A

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QUESTION: 19

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

provide community education to healthcare consumers
show a direct relationship between clinical documentation and quality patient care
create synergy between clinical education and CDI principles
promote CDI functions so that physicians view the CDI staff as value-added service

Answer(s): B

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QUESTION: 20

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

Complete
Legible
Precise
Reliable

Answer(s): D

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QUESTION: 20

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