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. Errors are corrected by the clinician who authored the documentation
• B. Amendments to record content must be co-signed by the attending physician
• 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

A patient's progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?

• A. The patient has acute on chronic systolic heart failure.
• B. The patient has decompensated systolic heart failure.
• C. The patient has chronic systolic heart failure.
• D. The patient did have an exacerbation of heart failure.

The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

• A. determine if only the treatment is documented and there is no diagnosis documented
• B. watch for reportable conditions or conditions that are unambiguous or otherwise complete
• C. identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
• D. look for documented conditions that have well supported accompanying clinical criteria

A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?

• A. No query is needed
• B. Query physician for POA
• C. Bring this case up in weekly Health Information Management meetings for further action
• D. Take the case to physician advisor/champion to discuss further action

A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

• A. Sepsis with pneumonia due to klebsiella pneumoniae
• B. Severe sepsis with pneumonia due to klebsiella pneumoniae
• C. Sepsis with respiratory failure due to pneumonia
• D. Septicemia due to klebsiella pneumoniae