Certified Documentation Improvement Practitioner (CDIP) — Question 20
A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?
Answer options
- A. Results of a survey of physicians that asks about documentation practices
- B. Incidence of redundancies in physician notes in a sample of hospital admissions
- C. Percent of insurance billings denied due to lack of record documentation
- D. Number of coder queries regarding inconsistent physician record documentation
Correct answer: D
Explanation
The correct answer is D because the number of coder queries indicates how often there are inconsistencies in physician documentation, highlighting the extent of the problem. Options A, B, and C provide indirect measures of documentation quality but do not specifically quantify the direct issue of inconsistencies in records.