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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

2. Yes/No queries may be used

A) in any query format
B) when only the clinical indicators of a condition are present
C) to resolve conflicting documentation from multiple practitioners
D) when the diagnosis is not clearly documented in the health record

3. Which of the following should be examined when developing documentation integrity projects?

A) Physician satisfaction surveys
B) Query rates from coding staff
C) Coding productivity statistics
D) CC and MCC capture rates

4. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

A) Amendments to record content must be co-signed by the attending physician
B) Errors are corrected by the clinician who authored the documentation
C) Any physician caring for the patient can correct inaccurate record notes
D) Coders can rely on the laboratory results to confirm the patient's diagnosis

5. An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?

A) Send a clinical validation query for both the diagnoses of sepsis and UTI.
B) Send a clinical validation query for only the diagnosis of UTI.
C) A clinical validation query is not required for either diagnosis.
D) Send a clinical validation query for only the diagnosis of sepsis.

Solutions: