DOCUMENT CLARIFICATION EXAM
WITH QUESTIONS AND CORRECT
SOLUTIONS| VERIFIED BY EXPERT|
2025 NEW UPDATE.
What is POA?
ANS: Present on admission.
What are concurrent reviews?
ANS: CDI specialist reviews the patient record while the patient is in the hospital.
What does "ethical" mean in the context of record review?
ANS: Conforming to accepted standards of conduct.
What are ethical queries?
ANS: Queries that do not lead the physician to a particular answer.
If you have two conflicting diagnoses by two providers, who should make the final
decision?
ANS: Attending physician.
What does "legible" mean in terms of record documentation?
ANS: The record is clear enough for the reader to comprehend and easily decipher.
What does "reliable" mean in the context of patient records?
ANS: The content of the record is trustworthy, safe, and yielding the same result when repeated.