Description: The Clinical Documentation Specialist (CDS) is responsible for concurrently reviewing the medical records of hospitalized patients to facilitate the accurate and complete representation of severity of patient illness through provider documentation. This involves extensive record review, interaction with physicians, mid - levels, residents, nursing, ancillary staff, and coders. Typical Duties: Identify new patient admissions and initiate review of documentation in the medical record utilizing clinical documentation software.
Review documentation daily or at an interval appropriate to that patient’s clinical picture. Establish working Diagnosis – Related Group (DRG) based on assignment of International Classification of Disease (ICD) diagnosis and procedure codes. Identify opportunities to impact case mix through documentation of complicating and comorbid, or major complicating and comorbid conditions and formulate a provider query based on query guidelines with timely provider follow-up.
Complete provider clarification queries per guidelines for instances in which documentation in the medical record is ambiguous, incomplete or conflicting and provide timely provider follow-up, as needed. Attend medical staff department meetings and present current clinical documentation trends, findings and provide education on the impacts of clinical documentation. Initiate Task Force meetings with the coding staff to discuss DRG assignment discrepancies and create participatory educational sessions regarding clinical conditions, documentation and coding.
Performs other related job duties as assigned.