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
Clinical Documentation Specialist - Key Responsibilities
- Facilitates and obtains appropriate physician documentation for all clinical conditions and procedures to accurately reflect the patient's severity of illness, risk of mortality, and complexity of care.
- Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional details within the health record as needed.
- Completes initial reviews of patient records within 24-48 hours of admission for an assigned patient population to:
- Evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness.
- Initiate and maintain a review worksheet for each case.
- Conducts follow-up reviews every 2-3 days to support and confirm a working or final DRG assignment upon patient discharge, as necessary.
- Utilizes the Concurrent Query Structured Note in Allscripts to issue physician queries.
- Processes documentation queries requested by the coding department.
- Educates physicians and key healthcare providers on clinical documentation improvement (CDI) principles and the importance of accurate and complete documentation in the health record.
- Collaborates with case managers, nursing staff, and other ancillary team members to communicate and resolve documentation issues or physician queries prior to patient discharge when possible.
- Assists in preparing and presenting clinical documentation monitoring and trending reports for review with physicians and hospital leadership.
- Educates patient care team members regarding specific documentation requirements, reporting and reimbursement issues, and findings identified through daily and retrospective reviews or aggregate data analysis.
- Performs other duties as assigned by the department.
Qualifications
Graduate Accredited School of Nursing
Min Experience Type of Experience
5 to 7 years Acute Nursing Care in Hospital Environment
Preferences
Clinical documentation improvement and or ICD-10 coding experience.
Additional Information
Licensing Requirements
Certificates/Licenses/Registration
Active FL RN License
CCDS - Certified Clinical Document
Preferences
Additional Information
CCDS required within 4 years of hire or transfer date.
