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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

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

2. Which of the following indicates a noncompliant multiple-choice query? One that does NOT

A) allow the provider to add their own response
B) include the option of "unable to determine"
C) include at least four options
D) list options in alphabetical order

3. A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?

A) Alert senior leadership to the record documentation problem
B) Bring together a team of physicians and informatics specialists
C) Gather data on the incidence of inaccurate record documentation
D) Recommend the physicians to be involved in the project

4. A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame. What should the CDIP do next?

A) Escalate issue to hospital administration
B) Query surgical consultant
C) Escalate issue to medical staff leadership
D) Query wound care nurse

5. A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?

A) Look for wound care documentation
B) Query the attending provider
C) Review the history and physical
D) Read the nursing admission notes

Solutions: