Clinical Documentation Spec - HIM-Clinical Doc Integrity - 016

Job description

Job Duties & Responsibilities Daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans. Ensures that the medical record documentation provides an accurate representation of the patient’s clinical care, diagnosis, severity, and expected risk of mortality sufficient to support APR-DRG assignment. Communicates with physicians and other healthcare team members, face to face or via clinical documentation inquiry forms regarding missing, unclear, or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness. Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team. Utilizes nursing critical thinking to identify clinical indicators for potential physician queries. Provides concurrent review and analysis of clinical information through electronic medical record...