Certified Inpatient Coding (CIC) Practice Exam

Which statement accurately reflects how Electronic Health Records (EHR) assist with clinical documentation improvement (CDI)?

1. They provide physicians with feedback after documentation is complete

2. They can replace the need for physician documentation

3. They prompt physicians for additional information

4. They are limited to data storage without decision support

The correct answer is: They prompt physicians for additional information

The chosen answer highlights a key functionality of Electronic Health Records (EHR) in enhancing clinical documentation improvement (CDI). EHR systems are designed to prompt users, particularly physicians, for additional information that may be necessary for comprehensive documentation. This capability encourages the inclusion of relevant details that may enhance the accuracy and completeness of patient records. By doing so, EHRs contribute to better coding outcomes and facilitate improved patient care, ensuring that all pertinent information is captured during the documentation process. In the context of CDI, this prompting feature is crucial as it supports compliance with regulatory and reimbursement standards while enhancing clinical communication. An EHR that actively engages the physician to fill gaps in documentation fosters a more thorough understanding of patient conditions and treatment plans, ultimately contributing to better health outcomes. The other statements do not accurately reflect how EHRs assist with CDI. For instance, feedback after documentation is complete may not provide the immediate support necessary for enhancing documentation at the point of care. Saying that EHRs can replace the need for physician documentation overlooks the essential role that medical professionals play in recording clinical information. Lastly, the characterization of EHRs as merely data storage systems without decision support is an incomplete view, as many EHRs include advanced decision-support tools that aid