Question 1: List and describe the seven criteria for high-quality clinical documentation. Why is a CDI program necessary? Don't physicians document correctly already?
Question 2: List and describe key types and sources of documentation. Why can't nursing notes be used?
Question 3: Describe the steps to development and implementation of a CDI program. Is it better to hire a consultant to set up the program or start one independently?
Question 4: Describe the CDI process. What should happen if the HIM coder's abstract does not agree with the CDI specialist worksheet?
Question 5: Finally, develop an appropriate physician query to resolve data and coding discrepancies (make your own scenario.)