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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for clinical significance of the CXR results.
B) Query the physician to clarify if CXR result means patient has pneumonia.
C) Query the physician to clarify if patient has acute COPD exacerbation.
D) Query the physician to clarify for type of COPD such as severe asthma.

2. An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A) PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure
B) PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
C) PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion
D) PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion

3. When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?

A) Admitting
B) Surgical
C) Consulting
D) Credentialing

4. For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

A) The name of the medication (aspirin), the date and time it was last administered
B) The name of the medication (aspirin), the date and location where it was last administered
C) The name of the medication (aspirin) and the date it was last administered
D) The name of the medication (aspirin), the date, time and location where it was last administered

5. Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?

A) Query the physician to see if acute renal failure with tubular necrosis is supported
B) No query is needed because the patient was dehydrated
C) Query the physician to see if acute renal failure is clinically supported
D) Code acute renal failure since symptoms are there and documented

Solutions: