Clinical Documentation Specialist , RN - F/T Days

The Clinical Documentation Specialist RN facilitates improvement in the overall quality, completeness and accuracy of medical record documentation for assigned hospital / s of Hackensack Meridian Health (HMH).

Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department (ETD), to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate.

Educates all members of the patient care team on documentation guidelines, on an on-going basis. Reviews and screens ED inpatient admissions and observations as specified by the facility's Utilization Management / Review Committee for documentation completeness and compliance with patient status.

Facilitates accurate documentation for severity of illness and medical necessity. Interacts with physicians, case managers, and nursing staff and provides guidance and recommendations for admission or observation disposition.

Assesses patients for present-on-admission (POA) conditions to ensure accurate documentation, regarding hospital acquired conditions (HAC).

Communicates the transfer of appropriate concurrent information to the inpatient Case Managers and the Clinical Documentation Specialists (CDS), assigned to the unit.

A day in the life of a Clinical Documentation Specialist RN at Hackensack Meridian Health includes :

• 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 the medical screening process by documenting appropriateness of patient admission, working DRG & LOS information 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 3M 360 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 3M 360 worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate.
• Updates 3M 360 worksheet to reflect any changes in DRG and / or APR assignment.
• Communicates with physicians to ensure that requests for documentation have been noted.
• Confers with physicians 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 the patient's chart.
• As appropriate, documents and analyzes data and reports instances of inappropriate patient care, discharge delays, etc.

to leaders of Health Information.

• Follows established department process for follow-up reviews and physician communication.
• Reviews clinical issues with coding staff to assign working DRG using software.
• Collaborates with coding staff as needed to determine appropriate DRG and required documentation.
• Utilizes coding staff knowledge of Coding Clinics that impact CDMP.
• Provides clinical expertise and references to the coding staff.
• Follows established guidelines for reconciling final coded DRG with the CDMP DRG assigned at the time of discharge.
• 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.

• Attends and participates in weekly educational conferences.
• Participates in concurrent performance improvement activities and on-going MR review activities.
• Reviews 3M 360 tracking data in conjunction with established benchmarks.
• Provides overview of CDMP to new staff, allied health professionals and physicians.
• Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Coding Compliance Manager, Department Director and Eme
10 days ago