CLINICAL DOCUMENTATION SPEC RN
Company: Hackensack Meridian Health
Posted on: January 15, 2020
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, 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 patient care team on documentation
guidelines, on an on-going basis. The CDS 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. The CDS 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.
1. Facilitates appropriate clinical documentation to ensure the
level of services and acuity of care are accurately reflected in
the medical record. 2. Performs admission reviews for specific
patient populations using clinical documentation guidelines. 3.
Assists in medical screening process by documenting appropriateness
of patient admission, working DRG & LOS information on worksheet
and computer system as appropriate. 4. Extensively reviews all
physician and clinical documentation, lab results, diagnostic
information and treatment plans and captures appropriate
information on CDMP / 3M 360 worksheet. 5. Utilizes clinical skills
to identify documentation opportunities that reflect severity of
illness, acuity and resource consumption. 6. Verbally communicates
with appropriate physician(s) to ensure documentation opportunities
are clarified. 7. Communicates with ancillary personnel (e.g., PT,
ET) to clarify potential documentation opportunities. 8. Updates
DRG worksheet to reflect any changes in patient status,
procedures/treatments, and confers with physician to finalize
diagnoses. 9. Reviews medical record every 24-48 hours as
appropriate. 10. Updates CDMP / 3M 360 worksheet to reflect
additional physician documentation, lab findings, diagnostic test
results and treatment as appropriate. 11. Updates CDMP / 3M 360
worksheet to reflect any changes in DRG and/or APR assignment. 12.
Communicates with physician to ensure that request for
documentation has been noted. 13. Confers with physician to
establish appropriate severity of illness and ensure documentation
of principal diagnosis, comorbid conditions, complications and
procedures. 14. Conducts follow-up reviews of clinical
documentation to ensure issues discussed and clarified with the
physician have been documented in patient\'s chart. 15. As
appropriate, documents and analyzes data and reports instances of
inappropriate patient care, discharge delays, etc. to Director of
Health Information. 16. Follows established CDMP process for
follow-up reviews and physician communication. 17. Reviews clinical
issues with coding staff to assign working DRG using software. 18.
Collaborates with coding staff as needed to determine appropriate
DRG and required documentation. 19. Utilizes coding staff knowledge
of Coding Clinics that impact CDMP . 20. Provides clinical
expertise and references to the coding staff. 21. Follows
established guidelines for reconciling final coded DRG with the
CDMP DRG assigned at the time of discharge. 22. 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. 23. Attends
and participates in weekly educational conferences. 24.
Participates in concurrent performance improvement activities and
on-going MR review activities. 25. Reviews CDMP / 3M 360 tracking
data in conjunction with established benchmarks. 26. Provides
overview of CDMP to new staff, allied health professionals and
physicians. 27. Maintains positive and open communications with
physicians, interdisciplinary care team members, coding staff,
Coding Compliance Manager, Department Director and Emergency Trauma
Dept. 28. Screens ED inpatient admissions and observations
determining the necessity and appropriateness of hospitalizations
using facility criteria. 29. Recommends admission or observation
disposition to the ED physician in accordance to the screening. 30.
Collaborates with admitting physician to place patient in
appropriate status. 31. CDS must attend/participate in
Multidisciplinary Rounds (MDR) of their designated/assigned unit.
32. Communicates with physician when screening criteria is not met
for inpatient and requests additional documentation if appropriate.
33. Reviews medical record for completeness and accuracy for
severity of illness (SOI) using the Compliant Documentation
Management Program (CDMP ) documentation strategies. 34. Initiates
CDMP / 3M 360 severity worksheet for inpatients. 35. Requests
documentation clarification as appropriate for SOI. 36. Assesses
all appropriate admissions for POA documentation of: a. Pressure
ulcers. b. Vascular-catheter associated infections. c. Indwelling
urinary catheter associated infections. d. Surgical Site infection
(mediastinitis). e. DVT, Pulmonary embolus. f. Risk for falls. 37.
Documents assessments in the medical record. 38. Initiates core
measure review as indicated for specific clinical topics: a. AMI.
b. Pneumonia. c. Heart Failure d. Stroke e. Severe Sepsis & Septic
Shock f. Upon identification of Core Measures, follow and adhere to
CDMP Core Measures protocols. g. Upon identification of Patient
Safety Indicators (PSIs), follow PSI flowsheet and adhere to CDMP
protocols. 39. Provides ongoing education to ED and admitting
physicians regarding appropriate documentation and criteria for
admission, observation, and level of care to comply with federal
and state mandates. Uses Milliman and Medicare and other
appropriate resources. 40. Maintains liaison with the inpatient
case manager and communicates necessary follow up. 41. Maintains
liaison with inpatient CDS and provides report summary. 42
.Performs other related job duties as requested. 43. Adheres to the
standards identified in the Medical Center\'s Organizational
Education, Knowledge, Skills and Abilities Required: 1. Graduation
from a program of nursing. 2. Ability to interact well with
physicians and other members of allied health care team, including
HIM coders. 3. Must be computer literate, have working knowledge
and familiarity of Microsoft Word and Excel/Windows based software
programs. 4. Must possess excellent communication, organizational,
analytical, writing and interpersonal skills. 5. Dependable,
self-directed and pleasant. 6. Critical thinking, problem solving
and deductive reasoning skills. 7. Recent hospital experience. 8.
Knowledge of Pathophysiology and Disease Process. 9. Knowledge of
Medicare Part A. 10. Familiar with Medicare Part B. 11. Knowledge
of regulatory environment. 12.
Meridian Health is committed to the principles of equal employment
opportunity and affirmative action and will not discriminate in the
recruitment or employment practices on the basis of race, color,
creed, national origin, ancestry, marital status, gender, age,
religion, sexual orientation, gender identity/expression,
disability, veteran status and any other category protected by
federal or state law.
Keywords: Hackensack Meridian Health, Hackensack , CLINICAL DOCUMENTATION SPEC RN, Healthcare , Hackensack, New Jersey
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