A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for pseudomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would:
Answer(s): D
Whether or not queries should be kept as a permanent part of the medical record is decided by
A patient was admitted due to possible pneumonia Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.Discharge diagnoses:1. Pneumonia2. COPD3. Current smokerWhat is the correct diagnostic related group assignment?
Answer(s): A
The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to
Answer(s): B
Which of the following criteria for clinical documentation means the content of the record is trustworthy; sage, and yielding the same result when repeated?
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