Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and Health Information Management coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis.
Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record
Performs admission reviews for specific patient populations using clinical documentation guidelines
Assists in medical screening process by documenting appropriateness of patient admission, working DRG & LOS info on worksheet and computer system as appropriate
Extensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and captures appropriate information on CDMP® worksheet
Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption
Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified
Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities
Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses.
Reviews medical record every 24-48 hours as appropriate
Updates Clinical Documentation Management Program worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate
Updates Clinical Documentation Management Program worksheet to reflect any changes in DRG assignment
Communicates with physician to ensure that request for documentation has been noted
Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures
Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient’s chart
As appropriate, documents, analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Manager of Health Records Services
Collaborates with coding staff as needed to determine appropriate DRG and required documentation
Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance
Participates in concurrent performance improvement activities and on-going MR review activities
Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Regional Manager of Coding, Quality and Compliance
