Overview
The Clinical Documentation Specialist conducts medical record reviews and identifies documentation needs within the medical record. The position also communicates, either verbally or in writing, with health care providers to address those needs in the medical record.
Responsibilities
- Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.
- Query physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
- Completes initial reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet.
- Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary.
- Use the concurrent query structured note in Allscripts to query physicians.
- Processes queries requested by the coding department.
- Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
- Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge when possible.
- Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
- All other duties as assigned by department.
Qualifications
Education Required:
- Associates degree in nursing
Experience Required
- 5 years of acute nursing experience
Experience Preferred
- Clinical documentation improvement and/or ICD-10 coding experience
- CCDS required within 2 years of hire