Health Information Personnel Practice Test

What do Clinical Documentation Improvement (CDI) specialists review?

1. Billing Codes

2. Insurance Policies

3. Patient's Electronic Health Records

4. Pharmacy Inventories

5. Research Articles

6. Surgical Instruments

The correct answer is: Patient's Electronic Health Records

Clinical Documentation Improvement (CDI) specialists focus on enhancing the accuracy, completeness, and specificity of clinical documentation within a patient's electronic health records (EHR). Their primary goal is to ensure that the documentation reflects the true complexity and nuances of a patient's health status and treatments. This accurate documentation is vital for several reasons, including proper coding for billing purposes, quality reporting, and compliance with regulatory requirements. By reviewing and ensuring the quality of EHRs, CDI specialists help healthcare providers convey the necessary clinical information that supports diagnoses, justifies the level of care provided, and supports the continuity of care among providers. They also play an important role in improving data for reporting outcomes and facilitating better healthcare delivery. The other options listed, such as billing codes, insurance policies, pharmacy inventories, research articles, and surgical instruments, do not pertain to the CDI specialty's primary focus. Instead, those areas involve different aspects of healthcare management and operations rather than the core responsibility of ensuring proper clinical documentation.