Pediatric Clinical Documentation Improvement. Personal Hx. about the possibility of a progressing infection; we discussed the possibility of a systemic Clinical documentation improvement is a prevailing topic in the health care industry. Specificity and accuracy are a byproduct of both relevant (things they see every day and … 3, July 2012 Clinical Documentation website: http://facets.parknicollet.com/cdmp/ The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in "real time" so that it is fit for reporting, analysis and … Clinical Documentation Specialists provide support to medical staff by analyzing medical information. After the documentation is translated into the alpha-numeric codes submitted in claims, the data are analyzed to generate results on quality and clinical outcome measures, in addition to payments. Cardiovascular: Hypertension Poor documentation may also affect quality of patient care because all elements aren’t captured accurately or considered based on a practitioner’s findings. Tailor your resume by picking relevant responsibilities from the examples below and then add your accomplishments. ... CDI Audit, cdi staffing, clinical documentation improvement Post Permalink. Informed providers of policy and regulation changes and any updates to the billing charge tickets. She will pick him Required clinical documents, once entered into the medical record, become part of a legal document. 142/92, Pulse 82, WD obese pleasant male well known to me, he is concerned today because he says he feels badly and The provider expresses concern for the patient’s condition. You can ref more useful materials for Clinical documentation improvement specialist job application such as Clinical documentation improvement specialist interview questions and answers, Clinical documentation improvement specialist resume samples, Clinical documentation improvement specialist job … Psychiatric: Normal, age appropriate Glucophage This program is designed to provide a true representation of the impact clinical documentation Instruct the provider to document the follow up plan. Ability to think critically and analytically, anticipate challenges and trends required, Working knowledge of automated system designs is preferred, Experience in computerized hospital/health information management systems and software applications is required, CDI Outpatient, Case Management and UR experience a plus, Direct experience in working as a CDI Leader or in development of CDI program in the acute care setting and understanding of CDI program infrastructure, workflow and reporting/metrics, Experience leading a large scale consulting project or driving implementation of a client CDIP, Proven success in delivering value to customers through the CDI programming, Strong communication skills including the abilities to present effectively, actively listen and influence/negotiate, Experience in conducting gap analysis, identification of risk and opportunity and development of findings and recommendations, including development of a Road Map, CDIP gap analysis experience preferred but qualified candidates may have comparable experience with other similar initiatives, Strong understanding of both clinical, HIM, Quality and Case Management workflow, Clinical Documentation Improvement Specialist/Professional (CCDS/CDIP) credentials through AHIMA or ACDIS, Direct experience in working as a CDI Specialist or in development of CDI program in the acute care setting and understanding of CDI program infrastructure, workflow and reporting/metrics, Experience in conducting gap analysis, identification of risk and opportunity and development of findings and recommendations, including development of a Road Map; CDIP gap analysis experience preferred but qualified candidates may have comparable experience with other similar initiatives, Individual must be proficient in ICD10 Diagnosis/Procedures Codes, MS-DRG reimbursement and clinical documentation requirements (coder credentials not required), Has facilitated physician education or has experience in working directly and communicating with physicians, Preferred license/credential: RN, NP, PA, MD, RHIA, RHIT, Knowledge of MS-DRG classification and reimbursement structures, Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation, Leadership and organizational skills along with critical, deductive reasoning and problem solving skills, Overall knowledge of the flow of the revenue cycle, Manage change while minimizing interruption at an operational and service level, Preferred: Graduate from a Nursing program, BSN or graduate of Health Information Management RHIT, RHIA, Coordinates and provides ongoing education to care providers regarding documentation requirements for optimal data integrity, data reliability, and clinical coding. Bachelor's Degree or MD (medical degree) a plus, Clinical documentation improvement experience highly preferred, In addition to education, 3 to 5 years of well-rounded medical or surgical acute care nursing and/or critical care nursing experience required, Technical knowledge of ICD-9 and 10, DRG and APR assignment and prospective payment methodologies preferred, Strong knowledge of clinical documentation guidelines required, Must be detail oriented, have the ability to work independently, exercise good judgment and be resourceful, Must display proficient communication skills, both written and verbal, Ability to write reports independent of management review is a plus, Experience and/or knowledge of regulatory compliance issues facing the healthcare industry is also a plus, Ability to manage execution by balancing time, resources, and quality constraints to achieve goals required. Physician Education in Clinical Documentation Improvement: Accurately Documenting and Supporting Diagnoses in the Delivery of Medically Necessary and Appropriate Healthcare Marianne Ries, MD, MBA, CPE Revenue Cycle and Institute for Population Health . Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. an electronic health record system for documentation must incorporate all CCBHS-MHP required documentation elements identified in CCBHS-MHP’s Policy 709. 230 Lbs, BMI 34 Temp. Develops and implements action plans to maximize the CDI program in the division, Facilitates the development and review of division/facility CDI plans to ensure compliance with internal audits, state and federal regulatory requirements. Musculoskeletal: In examining … Self-Paced Clinical Documentation Improvement (CDI) Inpatient-Outpatient Academy . No history of a heart betterment of public health clinical documentation improvement introduction icd 10 cm chapter 1 systemic infection inflammation meningitis hepatitis mrsa mssa herpes simplex chapter 2 neoplasms chapter 3 anemia hemolytic anemia nutritional anemia aplastic anemia pancytopenia coagulopathy purpura chapter 4 diabetes obesity malnutrition chapter 5 alcohol tobacco and tance usesubs major … discussed all of this over the phone with his daughter and she is in agreement. She says the albuterol is helping her breathing. Truth time – how thorough is your physicians’ documentation? The use of "non-contributory" is not permitted based on most Medicare Administrative Contractors (MAC). Below are three successful clinical examples of quality improvement in healthcare covering a wide range of issues facing many health systems today. DTRs are normal. For example, codes reflecting severity of illness and risk of mortality are used to risk-adjust data in order to avoid penalizing clinicians who care for sicker patients. When the patient describes pain, it is important to know the anatomic site of the pain. Zantac In partnership with Clinical Coders, ensures patient classification and DRG assignment are supported by physician documentation and in compliance with rules, regulations and guidelines, Frequently monitors productivity of Clinical Documentation Specialists and addresses concerns when minimum levels are not met, Communicates and informs Director of status of program and identifies any obstacles in meeting goals and objectives. Pick Your Poison: •Declining … Disclosures Drs. discussed all of this over the phone with his daughter and she is in agreement. This Clinical Documentation Manual is to be used as a reference guide and is not a definitive single ... and Quality Improvement & Utilization Review Department’s interpretation and determination of documentation standards. Clinical Documentation Specialist Resume Examples. A good resume is a one-page value proposition with clearly structured blocks and a clean, easy-to-read format. Ask the provider if the DM is uncontrolled. Clinical Documentation Specialist Job Description Example/Template. Minimum 2 years Director/Manager or Supervisory experience required, Assures appropriate reimbursement and administrative data-driven quality metrics through documentation improvement activities, Develops and delivers basic, intermediate and advanced level education for CHS physicians, coders, CDIS and leadership relating to, Keeps abreast of regulatory changes related to coding and documentation and communicates these changes to appropriate corporate and hospital staff, Maintains a thorough knowledge of the Medicare Inpatient Prospective Payment System, Possesses an excellent understanding of coding practices, official coding guidelines and federal regulations, Maintains a broad knowledge of ethical and compliant query practices, Maintains a broad knowledge of the clinical aspects of diagnoses and procedures to ensure appropriate documentation and compliance with respect to regulatory requirements for coding and billing, Possesses a broad knowledge of pharmacological usages and related adverse reactions, Maintains auditing skills for coding quality and documentation, Possesses the ability to develop and present effective education via a variety of media platforms, Possesses the ability to produce and analyze reports in a variety of platforms, Degree concentration in Health Informatics and Information Management, Health Care Administration, or clinical background such as Registered Nurse or comparable clinical experience, Three to five years of experience in an acute care hospital setting required, Three years of experience in providing physician and coder education required, Minimum of three years of clinical documentation improvement experience required, Must exhibit extensive knowledge of healthcare regulations, including reimbursement and documentation requirements, Must exhibit extensive knowledge of documentation requirements for severity of illness, risk of mortality, APR-DRGs and quality outcomes data, Previous experience working in a clinical documentation improvement department or as a consultant required, Minimum of one-year auditing experience preferred, 5 years experience in a CDI program with at least 3 years of experience as a manager or director in an acute care setting is required, Experience in conducting gap analysis, identification of risk/opportunities and development of findings and recommendations is required, Subject matter expertise in the area of clinical documentation to ensure the completeness of the patient records using multidisciplinary and interdisciplinary teams, High degree of hospital coding knowledge, including but not limited to APR-DRG, MS-DRG, HCCs, Medicare, Medicaid & Managed Care, in order to design and develop strategies to yield improvements to documentation that will improve overall patient quality, capture severity, assess acuity and determine risk of mortality, Thorough knowledge of clinical documentation requirements, clinical procedures, disease processes, treatments, and the patient populations served, Subject matter expertise regarding quality and reimbursement implications of clinical documentation and coding, Up-to-date knowledge of ICD-10 mandate and the impact of code set transition, including potential impact on data quality for prospective payments, utilization, and reimbursement, Demonstrated familiarity and adept use with software and technical applications including but not limited to: Microsoft Office products (Outlook, Excel, Word, PowerPoint), Epic (Electronic Health Records), Quantum (end coders), Midas (databases), Quantitative analysis skills to include spreadsheet applications and statistics, The individual will be responsible in ensuring that all staffs under him/her are adequately trained and equipped to carry out their daily clinical documentation work, The position will play a key role in ensuring the success of major revenue cycle initiatives, The individual will define, implement and monitor strategies for improving clinical documentation resulting in quality of care, optimal case mix index and overall consistency of clinical documentation and coded data, The individual will facilitate modifications to clinical documentation through extensive interaction with physicians and midlevel providers, nursing staff, other patient caregivers and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, other payers), The individual, in conjunction, with other department heads (HIM, Case Management, Quality) will lead the effort to ensure that accurate DRG-based reimbursement for the hospital is achieved and claim denials are reduced, by ensuring documentation integrity, The individual will ensure the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes, The individual will develop strategies that will address risk adjustment and other quality measures that address hospital and physician performance, The individual will ensure that his/her team is abreast with regulatory and compliance changes that impact the department’s operation, The individual will review data/metrics with providers at Medical staff meetings as well as on individual physician basis, The individual will facilitate optimal collaborative relationships with the medical staff including education opportunities, utilization management, health information management and other clinical staff, The individual will evaluate regulatory changes and educate staff appropriately, The individual should have regular, reliable, predictable attendance in performance of essential job functions, The individual should have a thorough understanding of denials management and clinical appeal and will play an active role in denials management through formulation of strategies to minimize denials and drafting of credible appeals, The individual will work with hospital leadership, physicians, and other providers to improve the overall quality and completeness of clinical documentation in the medical record to ensure that an accurate reflection of the severity of illness and the quality of care is captured, The individual will work to educate providers on the value of more granular documentation to their quality scores, risk of mortality data, length of stay, and continuity of care for the patient, The role will interface with compliance, management, and key physician leaders at the hospital as it prepares strategically for a competitive future, The individual will perform other departmental duties listed in the position description and as assigned, Minimum of 5 years of clinical healthcare experience in an acute care hospital, Knowledge base of ICD-10-CM coding and understanding of Diagnostic Related Groups (DRGs) required, Minimum 5 years recent health information management, case management / utilization / quality review and/or other related clinical experience in an acute care facility required; 3 years acute care inpatient coding experience preferred, Minimum of 2 years of acute care case management experience preferred, Minimum of 2 years of acute care clinical documentation specialist experience preferred, Knowledge of PC based computer software (i.e Word, Excel, Access or similar system) preferred, Graduate of an accredited school of nursing or Health Information Management program, Working knowledge of Microsoft computer applications; excel, word, PowerPoint, etc, Excellent written, verbal and presentation skills required; excellent business judgment, decision making, and business savvy are also essential, Experience working collaboratively with IT, HIMS, and Clinical Operations are important, Strong understanding and appreciation for the automation of the revenue cycle functions and the engagement of the customer in that automated process, Knowledge of applied statistics, process analysis, and outcomes analysis, Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record, Ensures that all written requests to physicians for additional documentation support compliance and departmental policies, Demonstrates the ability to prioritize daily work activities is self-directed and is able to complete daily work assignments with limited supervision, Performs quality screening for assigned patient for accurate assignment of a PSI and HAC to inpatient encounters, Assists with and analyzes outcome data relevant to the target case type to promote complete and accurate documentation, Analyzes and evaluates the effect of CDI on quality outcomes, fiscal parameters, and system operations and implements strategies to resolve system, performance and patient variances, Maintain and update the CDI Dashboard to track CDI measures of success and bench mark department effectiveness, Serves as a liaison between the CDI team and the medical staff, Collaborates with physicians and appropriate healthcare providers regarding documentation requirements and trends, as needed, Provides classroom and one-on-one training for CDI staff including initial CDI process and concept training and on-going education related to new topics in CDI, coding and reimbursement in conjunction with CDI Manager, Develops and provides formal and informal physician and staff education related to documentation improvement, Attends educational programs to enhance knowledge of clinical area served, Leads and/or participates on committees within the department, and TGH relevant to clinical documentation improvement, Assists in audits of CDI team as needed, makes appropriate recommendations for workflow improvement and accuracy as needed, Collaborates with Coding leadership and serves as a as a liaison between departments, Performs reconciliation of charts and differences in DRG assignments, Adhering to the Association of Clinical Documentation Improvement Code of Ethics and American Health Information Management Association’s code of ethics related to query process, Works with providers related to query responses, education and training, Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS) or obtain and maintain certification within one year of employment, Greater than 5 years clinical experience and greater than 3 years experience as a Clinical Documentation Improvement Specialist, Preferred clinical experience with acute care experience at a large facility, Preferred experience with 3M360 Clinical Documentation and EPIC electronic medical record, Excellent communication and interpersonal skills; ability to communicate verbally and in writing with individuals of varying educational levels, Significant financial and analytical skills, Word, Outlook, Excel PowerPoint experience preferred, Analytical skills necessary to clinically assess medical records required, Revenue cycle assessments for hospitals, health systems, and diagnostic laboratories, Alignment and implementation of client/partner processes and Optum360 technology, Provide revenue cycle management services to client/partners in all areas of revenue cycle which includes, 2+ years of experience in a director or supervisory role in an acute care setting, 3+ years of experience clinical documentation experience, 6+ years of experience working in a clinical role in a multi-facility health system, Experience and comfort working at all levels of a health care organization, Ability to probe, analyze, synthesize and articulate complex subject matter so it can be easily understood, In-depth knowledge of the complete healthcare revenue cycle, Working knowledge of laboratory and hospital based IT systems, Graduation from a program of Nursing, BSN and/or Bachelors of Science in Health Information Management or related degree, Registered Health Information Administrator and/or Certified Coding Specialist certification, 8 years+ acute care experience with recent management or supervisory experience of clinical documentation program, Current RN licensure or obtain Florida License within 6 months or Registered Health Information Administrator or Certified Coding Specialist certification, Manages CDI department personnel and operations to include personnel management, education, training, work flow analysis, productivity, quality, and report management to ensure achievement of departmental goals and objectives, Facilitates appropriate clinical documentation reviews to support accurate assignment of diagnoses and procedure codes, severity of illness, risk of mortality, MCC/CC capture, appropriate POA assignment, PSI, HAC, and provider queries, Performs and/or monitors quality reviews to ensure compliance with regulatory requirements, accreditation standards, and industry best practices, Collaboratively works with coding, quality, care management, physician champions, and other key stakeholders to improve clinical documentation, Conducts data and root cause analysis and communicates clinical documentation opportunities and/or concerns to key stakeholders in a timely and effective manner, Contributes to CDI strategic planning and process improvement activities, Integrates Cleveland Clinic’s Improvement Model (CCIM) and tools into daily operations to drive best practices and outcomes (i.e. Loss is in both ears s, and sputum culture Office: negative X-Ray: Rx given X-rays! 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Dedicated RN experience with medical-surgical, pediatrics, as well as pre-op surgery & s and. A checkup this over the phone with his friend at River Crossing Assisted Center. May be more than 100 review questions to help prepare for the hospital 's clinical Improvement... Lower extremities are normal on exam see the provider to document the follow up plan Assisted Living yesterday. 3+ years of CDI is simple: engage clinicians to improve the Documentation of inpatient medical.! Aligning changes across the organization can capitalize on internal resources to improve t … Recognizing the value of Documentation...