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ACDIS Certified Clinical Documentation Specialist Sample Questions:
When reviewing a patient's chart in the ICU, a CDI specialist determines a query needs to be placed. As the query is being written, the attending physician is leaving the patient's room after completing rounds. Which of the following is the BEST action to take?
- A. Query the physician verbally
- B. Complete the written query and submit to the physician
- C. Wait to see what the physician documents
- D. Review another chart
Correct Answer: A 🗳️
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A patient undergoes colorectal surgery. On postoperative day 2, the physician documents "ileus." The record shows absent bowel sounds and abdominal distention, but the surgeon also states that delayed bowel function is expected at this stage of recovery. Which action is MOST appropriate?
- A. Automatically code postoperative ileus as a surgical complication
- B. Assign intestinal obstruction instead
- C. Query the provider regarding whether the ileus represents an expected postoperative condition or a complication
- D. Remove the diagnosis because postoperative ileus is never reportable
Correct Answer: C 🗳️
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A patient with active breast cancer is admitted solely to receive a scheduled cycle of antineoplastic chemotherapy. No complication or acute disease process is responsible for the admission. Which diagnosis is generally sequenced first?
- A. Malignancy-related fatigue
- B. Encounter for antineoplastic chemotherapy
- C. Immunosuppression
- D. Breast cancer
Correct Answer: B 🗳️
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A patient develops a surgical-site infection after abdominal surgery and is admitted with sepsis. The surgeon clearly documents "sepsis due to postoperative wound infection." Which diagnosis category is generally sequenced first?
- A. Fever
- B. Severe sepsis
- C. The systemic sepsis code
- D. The postprocedural infection code identifying the surgical-site infection
Correct Answer: D 🗳️
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A patient presents with fever, productive cough, and infiltrates in the right upper lobe per chest x-ray. The history and physical notes that the patient has pneumonia and hypotension. Cultures are drawn and the patient is admitted for IV antibiotics. On day 2, the patient's condition worsens, and the patient is transferred to the ICU for closer monitoring. The ICU physician documents sepsis. Which of the following statements is MOST accurate?
- A. Pneumonia is the principal diagnosis; no query needed
- B. Query for aspiration pneumonia as POA
- C. Sepsis is the principal diagnosis, no query needed
- D. Query for sepsis as POA
Correct Answer: D 🗳️
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