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1. What is the main goal of CDI (clinical documentation
improvement) in health care organizations?
a) To ensure accurate coding and billing for services
provided
b) To enhance the quality and safety of patient care
c) To facilitate communication and collaboration among
health care providers
d) *All of the above*
Rationale: CDI aims to improve the completeness, clarity,
and accuracy of clinical documentation, which can benefit
coding and billing, quality and safety, and communication
and collaboration.
2. Which of the following is an example of a CDI query to
a health care provider?
a) *Please specify the type and acuity of the patient's heart
failure.*
b) Please document the patient's blood pressure and pulse
rate.
c) Please order a chest x-ray for the patient with
pneumonia.
d) Please discharge the patient with a diagnosis of acute
bronchitis.
Rationale: A CDI query is a request for clarification or
additional information from a health care provider to
improve the documentation of a clinical condition or
treatment. Option a is a CDI query that asks for more
specificity about the patient's heart failure.
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