Clinical Documentation Special
Reviews inpatient medical records for identified payer populations on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation.
Works closely with HIM coding staff to assure documentation of discharge diagnosis (es) and any coexisting comorbidities is a complete reflection of the patient’s clinical status and care.
In collaboration with physician leadership, designs and implements specific tools to support medical record physician documentation.
Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff.
- Registered Nurse, State of Georgia.
- Minimum five (5) years experience adult inpatient med-surg or critical care. Case Management experience preferred.
- Basic computer skills in word processing and spreadsheet utilization
- Excellent interpersonal skills to develop relationships necessary to influence physician documentation processes
- Analytic skills necessary to clinically assess medical records
- Some knowledge of DRGs helpful.
- Excellent prioritization and organizational skills