1|Page
CDIP Practice Exam 2 — 2025 Certified Documentation
Improvement Practitioner Study Guide, AHIMA Practice
Test Questions, and Exam Preparation Tips
Get ready for the CDIP Practice Exam 2 (2025) with updated AHIMA-style practice
questions, answer explanations, and a detailed study guide. Master clinical documentation,
coding accuracy, and compliance to pass the Certified Documentation Improvement
Practitioner (CDIP) certification exam on your first attempt.
• CDIP practice exam 2 2025
• AHIMA CDIP practice test
• Certified Documentation Improvement Practitioner exam
A CDI program should be governed by policies and procedures. These policies and procedures
should be developed with the assistance of other departments affected by clinical
documentation, including compliance, case management, and what other department?
a.Information systems
b.Process improvement
c.Health Information Management (HIM)
d.Finance - ANSWER-c HIM These policies and procedures should be developed with the
assistance of other departments affected by clinical documentation, including compliance, case
management, and HIM (AHIMA 2013b).
Providers should maintain queries:
,2|Page
a.Indefinitely
b.Based on their facility policy
c.Never
d.Until the patient expires - ANSWER-b Based on your facility policy. Retention of the query
varies by healthcare organization. First, an organization must determine if the query will be part
of the health record. If the query is not part of the health record, then the organization must
decide if the query is kept as part of the business record or only the outcome of the query is
maintained in a database (AHIMA 2013b).
The new CDI manager has decided the query will become a part of the health record stating this
is required.
a.The query has to be a part of the health record
b.An organization must determine if the query will be part of the health record
c.The query should be disposed of after completion
d.All queries should be verbal - ANSWER-b It is the decision of an organization of how to
maintain queries and whether to include them as part of the health record. . Retention of the
query varies by healthcare organization. First, an organization must determine if the query will
be part of the health record. If the query is not part of the health record, then the organization
must decide if the query is kept as part of the business record or only the outcome of the query
is maintained in a database (AHIMA 2013b).
A CDI program should have ongoing monitoring to ensure CDI activities are being performed
compliantly and accurately. This process is called.
a.Quality Assurance Tool/Program
b.CDI Monitoring Tool/Program
c.CDI Checks and Balances Tool/Program
d.This process is not required as long as knowledgeable staff is utilized - ANSWER-a It is
important to implement a Quality Assurance Audit Tool/Program to perform review of CDI
functions and activities. It is important for a facility to have checks and balances in place to
,3|Page
ensure the highest level of integrity as CDI programs mature. External audits will be scrutinizing
health records closely for documentation, including those by RAC contractors. When developing
a CDI program, a strong QA process can aid in achieving a successful and compliant program
(AHIMA 2014a, 6).
A clinical documentation specialist (CDS) is employed at ABC hospital. She has been consistently
having conversations with the hospitalists on what they should document on every patient that
presents with fever and receives antibiotics. As director, you should:
a.Review the AHIMA Query Brief with the CDS
b.Review the escalation policy with the CDS
c.Ensure all staff have the same proactive approach
d.No attention to this area is needed - ANSWER-a Review the AHIMA Query Brief with the CDS.
Verbal queries should contain the same clinical indicators and follow the same format as written
queries to ensure compliance and consistency in policy and process. Documentation of the
verbal query may be condensed to reflect the stated information, but should identify the clinical
indicators that support the query as well as the actual question posed to the practitioner. Verbal
queries should be documented at the time of the discussion or immediately following (AHIMA
2013a, 50-53).
The CDS manager has been asked to assist with assessing or managing data quality for internal
external customers. This role is called the:
a.Chief Information Officer
b.HIM director
c.Quality analyst
d.Data manager - ANSWER-d Data manager. When tasked with assessing or managing data
quality, an HIM professional must first understand who the data consumers are. This involves
making a list of all of the internal and external consumers. Assessing the needs of data
consumers is challenging; a good data manager would ask the data consumer how they use the
data rather than what their needs are. The data manager must take a controlled and careful
approach to collecting data for consumer needs. It will be impossible for the data manager to
meet all the needs of all of the data consumers (Fenton and Biedermann 2014, 114-115).
, 4|Page
Erin is the HIM director at Anywhere Hospital. She is teaching a class to clinicians about proper
documentation in the health record. Which of the following would she not instruct them to do?
a.Obliterate errors
b.Leave existing entries intact
c.Label late entries as being late
d.Ensure the legal signature of an individual making a correction accompanies the correction -
ANSWER-a Any corrections to the record must be entered properly. In paper records, the
provider should draw a single line through the error, add a note explaining the error, initial and
date the error with the date it was discovered, and enter the correct information in
chronological order. For electronic entries, a procedure should be followed that explains how to
correct errors and enter addenda to the health record (Shaw and Carter 2014; LaTour et al.
2013, 264).
The Clinical Documentation Program at ABCD Medical Center has made significant strides to
improve their physician engagement at their facility and had reduced their physician response
to 98 percent over a one year period. Their CMO has recommended the team share their
success by:
a.Not put too much emphasis on the initiative
b.Publish this in a research journal for physician education and facility awareness
c.Make adjustments to their CDI process as 80 percent compliance is the facility goal
d.None of the above - ANSWER-b Performing research around the CDI initiatives and writing
publications can be beneficial for the CDI program and the facility. This co-development can also
foster physician understanding in the process and individual documentation accountability. To
communicate effectively, managers must pay just as much attention to how their message is
received and interpreted as they do to its content. In order to enhance the accuracy and
acceptance of communication, the communicator needs to monitor others' nonverbal behaviors
for cues that they are following or confused. Passive listening and distracted parties would not
enhance effective communication (Shaw and Carter 2014; Hess 2015, 231).
The financial statement that presents a record of operations by showing revenue and expenses
over a period of time is called the:
a.Income statement
CDIP Practice Exam 2 — 2025 Certified Documentation
Improvement Practitioner Study Guide, AHIMA Practice
Test Questions, and Exam Preparation Tips
Get ready for the CDIP Practice Exam 2 (2025) with updated AHIMA-style practice
questions, answer explanations, and a detailed study guide. Master clinical documentation,
coding accuracy, and compliance to pass the Certified Documentation Improvement
Practitioner (CDIP) certification exam on your first attempt.
• CDIP practice exam 2 2025
• AHIMA CDIP practice test
• Certified Documentation Improvement Practitioner exam
A CDI program should be governed by policies and procedures. These policies and procedures
should be developed with the assistance of other departments affected by clinical
documentation, including compliance, case management, and what other department?
a.Information systems
b.Process improvement
c.Health Information Management (HIM)
d.Finance - ANSWER-c HIM These policies and procedures should be developed with the
assistance of other departments affected by clinical documentation, including compliance, case
management, and HIM (AHIMA 2013b).
Providers should maintain queries:
,2|Page
a.Indefinitely
b.Based on their facility policy
c.Never
d.Until the patient expires - ANSWER-b Based on your facility policy. Retention of the query
varies by healthcare organization. First, an organization must determine if the query will be part
of the health record. If the query is not part of the health record, then the organization must
decide if the query is kept as part of the business record or only the outcome of the query is
maintained in a database (AHIMA 2013b).
The new CDI manager has decided the query will become a part of the health record stating this
is required.
a.The query has to be a part of the health record
b.An organization must determine if the query will be part of the health record
c.The query should be disposed of after completion
d.All queries should be verbal - ANSWER-b It is the decision of an organization of how to
maintain queries and whether to include them as part of the health record. . Retention of the
query varies by healthcare organization. First, an organization must determine if the query will
be part of the health record. If the query is not part of the health record, then the organization
must decide if the query is kept as part of the business record or only the outcome of the query
is maintained in a database (AHIMA 2013b).
A CDI program should have ongoing monitoring to ensure CDI activities are being performed
compliantly and accurately. This process is called.
a.Quality Assurance Tool/Program
b.CDI Monitoring Tool/Program
c.CDI Checks and Balances Tool/Program
d.This process is not required as long as knowledgeable staff is utilized - ANSWER-a It is
important to implement a Quality Assurance Audit Tool/Program to perform review of CDI
functions and activities. It is important for a facility to have checks and balances in place to
,3|Page
ensure the highest level of integrity as CDI programs mature. External audits will be scrutinizing
health records closely for documentation, including those by RAC contractors. When developing
a CDI program, a strong QA process can aid in achieving a successful and compliant program
(AHIMA 2014a, 6).
A clinical documentation specialist (CDS) is employed at ABC hospital. She has been consistently
having conversations with the hospitalists on what they should document on every patient that
presents with fever and receives antibiotics. As director, you should:
a.Review the AHIMA Query Brief with the CDS
b.Review the escalation policy with the CDS
c.Ensure all staff have the same proactive approach
d.No attention to this area is needed - ANSWER-a Review the AHIMA Query Brief with the CDS.
Verbal queries should contain the same clinical indicators and follow the same format as written
queries to ensure compliance and consistency in policy and process. Documentation of the
verbal query may be condensed to reflect the stated information, but should identify the clinical
indicators that support the query as well as the actual question posed to the practitioner. Verbal
queries should be documented at the time of the discussion or immediately following (AHIMA
2013a, 50-53).
The CDS manager has been asked to assist with assessing or managing data quality for internal
external customers. This role is called the:
a.Chief Information Officer
b.HIM director
c.Quality analyst
d.Data manager - ANSWER-d Data manager. When tasked with assessing or managing data
quality, an HIM professional must first understand who the data consumers are. This involves
making a list of all of the internal and external consumers. Assessing the needs of data
consumers is challenging; a good data manager would ask the data consumer how they use the
data rather than what their needs are. The data manager must take a controlled and careful
approach to collecting data for consumer needs. It will be impossible for the data manager to
meet all the needs of all of the data consumers (Fenton and Biedermann 2014, 114-115).
, 4|Page
Erin is the HIM director at Anywhere Hospital. She is teaching a class to clinicians about proper
documentation in the health record. Which of the following would she not instruct them to do?
a.Obliterate errors
b.Leave existing entries intact
c.Label late entries as being late
d.Ensure the legal signature of an individual making a correction accompanies the correction -
ANSWER-a Any corrections to the record must be entered properly. In paper records, the
provider should draw a single line through the error, add a note explaining the error, initial and
date the error with the date it was discovered, and enter the correct information in
chronological order. For electronic entries, a procedure should be followed that explains how to
correct errors and enter addenda to the health record (Shaw and Carter 2014; LaTour et al.
2013, 264).
The Clinical Documentation Program at ABCD Medical Center has made significant strides to
improve their physician engagement at their facility and had reduced their physician response
to 98 percent over a one year period. Their CMO has recommended the team share their
success by:
a.Not put too much emphasis on the initiative
b.Publish this in a research journal for physician education and facility awareness
c.Make adjustments to their CDI process as 80 percent compliance is the facility goal
d.None of the above - ANSWER-b Performing research around the CDI initiatives and writing
publications can be beneficial for the CDI program and the facility. This co-development can also
foster physician understanding in the process and individual documentation accountability. To
communicate effectively, managers must pay just as much attention to how their message is
received and interpreted as they do to its content. In order to enhance the accuracy and
acceptance of communication, the communicator needs to monitor others' nonverbal behaviors
for cues that they are following or confused. Passive listening and distracted parties would not
enhance effective communication (Shaw and Carter 2014; Hess 2015, 231).
The financial statement that presents a record of operations by showing revenue and expenses
over a period of time is called the:
a.Income statement
