CLINICAL DOCUMENTATION TOOLKIT
EXAM WITH QUESTIONS AND 100%
CORRECT ANSWERS VERIFIED AND
APPROVED BY EXPERT 2025 UPDATE.
What is CDI?
Any manual or electronic notation made by a clinical care provider or their authorized "medical
scribe."
What is the purpose of CDI?
The diagnosis and procedures documented in the record need to be clearly supported by clinical
indicators so that the ICD-10-CM/PCS codes assigned are accurate and correctly assigned.
What is a Written Query?
The method of clarification used by CDI professionals. Verbal and electronic are also methods
documented in the health record to make contact with the Physician.
What are the benefits of a CDI Program?
Accuracy and completeness in documentation, coding, reimbursement, and severity of illness
[SOI] and risk of mortality [ROM] classifications.
How do you begin a CDI Program?
A focused concurrent review of a specific payer type (such as Medicare) or payment type (such
as DRG).
Where are CDI Programs found?
CDI programs are typically found in the acute inpatient setting; they also exist in other
healthcare settings such as provider offices, ambulatory care, acute rehabilitation hospitals, and
skilled nursing facilities.
,Who are the CDI staff?
HIM Coding Professionals, Nurses, Provider Liaisons, or Provider Champions who conduct
reviews and communicate with other providers on documentation issues.
What are the knowledge, skills, and attributes of CDI professionals?
Clinical Knowledge, Payment Systems, Methodologies, ICD-10-CM/PCS Coding Concepts and
guidelines, Regulatory Compliance, experience in Hospital acute care, and strong verbal and
written communication skills.
What are the terms for "CDI Professionals"?
CDIP: Clinical Documentation Improvement Practitioner
CDIS: Clinical Documentation Improvement Specialist
CDS: Clinical Documentation Specialist
Who are the key CDI stakeholders?
CDI programs are seen as a bridge between:
HIM and Coding Departments
Case Management and Utilization Review
Medical Staff and Provider Leadership
Executive Leadership
Patient Financial Services or Billing
Finance and Revenue Cycle
Quality and Risk Management
Nursing Compliance and Ethics
What are the CDI goals?
Obtain clinical documentation that captures the patient SOI and ROM
Identify and clarify missing, conflicting, or nonspecific provider documentation related to
diagnosis and procedures
Support accurate diagnostic and procedural coding, MS-DRG assignment, leading to
appropriate reimbursement
Promote health record completion during the patient's course of care, which promotes
patient safety
Improve communications between physicians and other members of the healthcare team
Provide awareness and education
, Improve documentation to reflect quality and outcome scores
Improve coding professionals' clinical knowledge
What is the CDI concept that must be part of the CDI formula to achieve sustainable and
cost-effective success?
The CDI educational component that is supplemented and complemented by usable, efficient,
compliant, and meaningful documentation tools that enhance provider optimal patient care
workflow enhances one's success.
How can CDI programs be measured?
Tracking and trending CDI metrics, Key Performance Indicators (KPIs), and results is pivotal to
demonstrating that the goals and benefits of the program are being achieved.
What is a Query?
A tool to support the documentation improvement process of a CDI program. "Query" is used to
identify the provider communication tool used concurrently or retrospectively to obtain
documentation clarification.
What is an Electronic Query?
A process by which a physician can provide any clarification or specificity on the case by
creating an electronic document that is linked to the patient's EHR and made available as a
permanent part of the health record metadata.
What is a Paper Query?
A process that may use a standardized template seeking clarification or specificity and submitted
to the provider; and generally used in Hybrid record systems.
What is Query Management?
Maintained as part of the legal health record and will require more patient information than those
that are only part of the business record. Retention is determined by legal counsel.
EXAM WITH QUESTIONS AND 100%
CORRECT ANSWERS VERIFIED AND
APPROVED BY EXPERT 2025 UPDATE.
What is CDI?
Any manual or electronic notation made by a clinical care provider or their authorized "medical
scribe."
What is the purpose of CDI?
The diagnosis and procedures documented in the record need to be clearly supported by clinical
indicators so that the ICD-10-CM/PCS codes assigned are accurate and correctly assigned.
What is a Written Query?
The method of clarification used by CDI professionals. Verbal and electronic are also methods
documented in the health record to make contact with the Physician.
What are the benefits of a CDI Program?
Accuracy and completeness in documentation, coding, reimbursement, and severity of illness
[SOI] and risk of mortality [ROM] classifications.
How do you begin a CDI Program?
A focused concurrent review of a specific payer type (such as Medicare) or payment type (such
as DRG).
Where are CDI Programs found?
CDI programs are typically found in the acute inpatient setting; they also exist in other
healthcare settings such as provider offices, ambulatory care, acute rehabilitation hospitals, and
skilled nursing facilities.
,Who are the CDI staff?
HIM Coding Professionals, Nurses, Provider Liaisons, or Provider Champions who conduct
reviews and communicate with other providers on documentation issues.
What are the knowledge, skills, and attributes of CDI professionals?
Clinical Knowledge, Payment Systems, Methodologies, ICD-10-CM/PCS Coding Concepts and
guidelines, Regulatory Compliance, experience in Hospital acute care, and strong verbal and
written communication skills.
What are the terms for "CDI Professionals"?
CDIP: Clinical Documentation Improvement Practitioner
CDIS: Clinical Documentation Improvement Specialist
CDS: Clinical Documentation Specialist
Who are the key CDI stakeholders?
CDI programs are seen as a bridge between:
HIM and Coding Departments
Case Management and Utilization Review
Medical Staff and Provider Leadership
Executive Leadership
Patient Financial Services or Billing
Finance and Revenue Cycle
Quality and Risk Management
Nursing Compliance and Ethics
What are the CDI goals?
Obtain clinical documentation that captures the patient SOI and ROM
Identify and clarify missing, conflicting, or nonspecific provider documentation related to
diagnosis and procedures
Support accurate diagnostic and procedural coding, MS-DRG assignment, leading to
appropriate reimbursement
Promote health record completion during the patient's course of care, which promotes
patient safety
Improve communications between physicians and other members of the healthcare team
Provide awareness and education
, Improve documentation to reflect quality and outcome scores
Improve coding professionals' clinical knowledge
What is the CDI concept that must be part of the CDI formula to achieve sustainable and
cost-effective success?
The CDI educational component that is supplemented and complemented by usable, efficient,
compliant, and meaningful documentation tools that enhance provider optimal patient care
workflow enhances one's success.
How can CDI programs be measured?
Tracking and trending CDI metrics, Key Performance Indicators (KPIs), and results is pivotal to
demonstrating that the goals and benefits of the program are being achieved.
What is a Query?
A tool to support the documentation improvement process of a CDI program. "Query" is used to
identify the provider communication tool used concurrently or retrospectively to obtain
documentation clarification.
What is an Electronic Query?
A process by which a physician can provide any clarification or specificity on the case by
creating an electronic document that is linked to the patient's EHR and made available as a
permanent part of the health record metadata.
What is a Paper Query?
A process that may use a standardized template seeking clarification or specificity and submitted
to the provider; and generally used in Hybrid record systems.
What is Query Management?
Maintained as part of the legal health record and will require more patient information than those
that are only part of the business record. Retention is determined by legal counsel.
