CDIP Domain 3: Record Review and Document
Clarification Exam | Questions with 100% Correct
Answers | Verified | Latest Update 2026
Save
Terms in this set (47)
7 Criteria for High Quality Legibile
Documentation Reliable
Precision
complete
consistent
clarity
timeliness
Legibility Required under all government and regulatory
agencies
Reliability treatment provided without documentation of
condition being treated
Precision no specific diagnosis documented, more specific
diagonals appears to be supported
completeness abnormal test results without documentation for
clinic significance ( joint commission requirement
consistency disagreement between two or more treating
physicians without obvious resolutions of the
conflicting documentation upon discharge
, clarity vague or ambiguous documentation, especially in
the case of symptom principal diagnosis
timeliness documentation that is not complete within the
guidelines set by the facility, CMS, state, joint
commission, and other regulatory agencies
When to Query 1. clinical evidence for higher degree of specificity
or severity
2. clinical indicators of diagnosis without
documentation of the condition
3 cause and effect relationship between two
conditions or organism and condition
4. presence of underlying cause when admitted
with sypmtoms
5. documentation of only treatment without
diagnosis
6. POA indicators
7. Illegibility of documentation
8. site, laterality, type, stage
what to include in a query patient name, admission date(s) of service, Health
record number, account number, date of query,
name and contact of CDS/coder, statement of
issue
what is a statement of issue? written as a question, includes clinical indicators
from chart, ask provider to make clinical
interpretation of facts in chart.
Should NOT be presumptive, directing, prodding,
probing, or leading
Clarification Exam | Questions with 100% Correct
Answers | Verified | Latest Update 2026
Save
Terms in this set (47)
7 Criteria for High Quality Legibile
Documentation Reliable
Precision
complete
consistent
clarity
timeliness
Legibility Required under all government and regulatory
agencies
Reliability treatment provided without documentation of
condition being treated
Precision no specific diagnosis documented, more specific
diagonals appears to be supported
completeness abnormal test results without documentation for
clinic significance ( joint commission requirement
consistency disagreement between two or more treating
physicians without obvious resolutions of the
conflicting documentation upon discharge
, clarity vague or ambiguous documentation, especially in
the case of symptom principal diagnosis
timeliness documentation that is not complete within the
guidelines set by the facility, CMS, state, joint
commission, and other regulatory agencies
When to Query 1. clinical evidence for higher degree of specificity
or severity
2. clinical indicators of diagnosis without
documentation of the condition
3 cause and effect relationship between two
conditions or organism and condition
4. presence of underlying cause when admitted
with sypmtoms
5. documentation of only treatment without
diagnosis
6. POA indicators
7. Illegibility of documentation
8. site, laterality, type, stage
what to include in a query patient name, admission date(s) of service, Health
record number, account number, date of query,
name and contact of CDS/coder, statement of
issue
what is a statement of issue? written as a question, includes clinical indicators
from chart, ask provider to make clinical
interpretation of facts in chart.
Should NOT be presumptive, directing, prodding,
probing, or leading
