CDIP Documentation Integrity and Data Quality

Question 1

Which of the following BEST defines 'documentation integrity' in a clinical documentation improvement (CDI) context?

Accepted Answer

Ensuring health record documentation is accurate, complete, consistent, and reliable

Answer

Ensuring physician notes are lengthy and detailed

Answer

Limiting access to medical records to reduce errors

Answer

Standardizing all diagnoses to ICD-10 codes at the point of care

Question 2

A CDI specialist notices that a physician's discharge summary contradicts the nursing notes regarding a patient's mental status. This is an example of a failure in which data quality dimension?

Accepted Answer

Consistency

Answer

Accuracy

Answer

Timeliness

Answer

Granularity

Question 3

Which federal law establishes patients' rights to access and amend their health records and sets privacy protections relevant to documentation integrity?

Accepted Answer

HIPAA Privacy Rule

Answer

False Claims Act

Answer

HITECH Act

Answer

Stark Law

Question 4

A CDI specialist finds a late entry added to a medical record two weeks after discharge without proper identification of the addendum date and author. This practice primarily compromises which data quality attribute?

Accepted Answer

Auditability

Answer

Granularity

Answer

Accessibility

Answer

Precision

Question 5

Which of the following is the MOST appropriate CDI action when a progress note is illegible and could affect code assignment?

Accepted Answer

Submit a compliant physician query requesting clarification

Answer

Assign the most likely code based on context

Answer

Ignore the note and rely on other documentation

Answer

Delete the illegible entry and request a rewrite

Question 6

Which term describes the degree to which health data represent the smallest useful components needed for a given use, such as specifying 'left lower lobe pneumonia' rather than 'pneumonia'?

Accepted Answer

Granularity

Answer

Consistency

Answer

Accessibility

Answer

Currency