Clinical Documentation Registered Nurse II - Clinical Documentation Integrity

Responsibilities

• 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 - Maintains positive open communication with physicians, nursing and all other disciplines involved in the care of the patient - Works closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care - Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures - Updates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosis - Consistently meets established productivity targets for record review - Designs and implements in collaboration with physician leadership 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 on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies - Assists in collection and organization of data for analysis by appropriate medical and hospital committees - Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation - Demonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the department - Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served - Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities - Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties - Performs other duties as assigned