The Clinical Documentation Specialist facilitates modifications to clinical documentation through concurrent interactions with providers and other members of the healthcare team. The CDS promotes capture of physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care for the patient. Demonstrates ability to clinically evaluate how the health record translates into coded data, including review of provider and other clinician documentation, lab results, diagnostic information and treatment plans. Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing and case management. The CDS must be able to define problems, collect data, establish facts, and draw valid conclusions. The CDS must be able to interpret and deal with abstract and concrete variables and be able to effectively present information and respond to questions from physicians and other healthcare professionals.
The Clinical Documentation Specialist reports directly to the Director of Case Management.
Utilizes the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification. Completes initial reviews of patient records within 24-48 hours of admission for a specified patient population to a) evaluate documentation to assign the working DRG, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; b) initiate a review.
Conducts a follow-up review of patients daily for additional information or additional opportunities.
Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation within 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.
Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
Educate members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective reviews.
Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
Creates and monitors inpatient case mix reports and the top 25 assigned DRGs in the facility to identify patterns, trends, variances and opportunites in the facility’s frequently assigned DRG groups. Once identified, the Clinical Documentation Specialist evaluates the causes of the change or problems and takes appropriate steps in collaboration with the right department to effect resolution or explanation of the variances.
a.) Graduate from an accredited school of nursing or accredited Health Information Management Program
a.) RN, RHIA, RHIT, or CCS
a.) Strong healthcare background with at least 2- 4 years experience.