Because the patient presents with knee pain, the provider would perform a more thorough exam than what is documented. Medical Record # 06500. started "feeling bad" he complains of generalized fatigueand and over-the-counter Claritin. > Resume examples > Clinical Documentation Improvement Specialist Resume. A recent study, for example, found that EHR documentation and what actually happened during a clinical encounter only matched between 38 and 53 percent of the time. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical records, Demonstrate good knowledge in clinical documentation improvement, serving as a resource and participating in problem-solving opportunities, Resolve inconsistent, conflicting and/or ambiguous documentation through compliant physician query process in at least 85% of the cases, Follow up with physicians to get resolution of all queries prior to patient’s discharge in 85% of the cases, Demonstrate working knowledge of information systems related to job duties, Effectively utilize documentation improvement communication tools, Demonstrate proficiency in utilization of computer based tools in retrieving and maintaining inpatient census data, Perform daily reviews with input into available system using appropriate screening tool to facilitate ongoing auditing, monitoring and corrective action within the Clinical Documentation Improvement (CDI) process, Assist Performance Improvement and Quality Departments in improving clinical documentation for compliance in quality of care measures (esp. Ensure documentation accurately reflects medical necessity, severity of illness, medical care plan, and risk of mortality. Assist clinicians in being aware of communication issues and if the hearing loss is in both ears. He does have a prosthetic joint. Below is a sample cover letter for Clinical documentation improvement specialist position. Headline : A certified Clinical Documentation Improvement Specialist (CDIS) with over three years of active acute-care in-patients experience, a Physician with over eight years of clinical practice, an ICD-10 trained. He has a history of a total joint replacementin For older jobs, though, you can cut down to five or fewer. The courses also include more than 100 review questions to help prepare for the CDIP exam. Instruct the provider to document if the test was performed in the office today or at another site. Medications: DRG assignments and codes affect billing and, if assigned erroneously, can lead to denied claims or inaccurate reimbursements. Cardiovascular: Hypertension 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 … Every site can have a different CDI plan. According to The American Health Information Management Association (AHIMA), CDI is so important in the health care world because it has a direct impact on patient care. A clinical documentation improvement program is a dedicated team of healthcare professionals that will assure that the medical record documentation reflects an accurate picture of the patient's diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care. Patient Name: Jonathan P. Smith Neurological: Sensation is normal. Concurrent and retrospective reviews ; Work with physicians to improve the documentation of inpatient medical records. Type II DM, Elevated Glucose, 250.02250.02 250.00 Clinical documentation is the catalyst for coding, billing, and auditing, and is the con-duit for (and provides evidence of) the quality and conti-nuity of patient care. 5. Team members at Allina want to build on their program’s success and further leverage the CDI analytics application. Well healed incision from previous surgery This small rural hospital is a 30-bed, fully paper-health dependent facility. In some cases, bringing in an … You'll learn the skills that will ultimately protect revenue and minimize your exposure to risk. Living Center yesterday. Experience in both areas preferred, Use your extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines, Verify clinical documentation against final coding and modify CDI technology entry in order to report valid CDI outcomes, Reviews clinical issues with the coding staff to assign a working DRG, Participate in patient care conference/case conferences to identify needs for clinical documentation, Maintain current skill set with regard to government regulations, compliance and reimbursement guidelines, Expected to keep abreast of new legislation and regulations that affect CDI, Provide input for reporting of metrics and measures of CDI program activity to hospital executive and medical leadership, Maintains personal and professional education and growth, Responsible for maintaining continuing education credits as required by credentialing organization, RN Required. The type of diabetes must be documented. In a previous blog post, More Than Just HCC’s: 6 Best Practices for Outpatient CDI, we discussed the areas that need to be addressed in a comprehensive outpatient clinical documentation improvement (CDI) program.While we recommend going beyond just focusing on Hierarchical Condition Categories (HCC’s), taking a closer look at documentation related to HCC’s is a good place to start. Complete and deliver a follow-up report to client, Responsible for providing education and training on clinical documentation improvement principals and methodology (MS-DRG and APR-DRG as appropriate) to the Strategic Sourcing clients, Consulting Practice, and new clients, Educate team and clients on Precyse CDI technology and associated work flows during implementations that combines CDI services and technology, Work in collaboration with Director of Clinical Services Consulting Practice to develop / refine education materials, participate in internal training and client management, Supports Precyse's Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by training participation and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient information, Must have high speed internet access and experience with remote access, set-up, and troubleshooting technical issues when working remotely, Weekend travel may be required on occasion, RN or MD Required. It is important to instruct provider to document which extremities because extremities alone does not mean the physician examined all four extremities. Resp. No need to think about design details. to capture best practice documentation for specific diagnoses. Recognizing the Value of Clinical Documentation Improvement. Surprised by the hints? You would never put your sick child in the hands of a physician with no pediatric experience. Respiratory:  c/o nagging cough Critical for indication of when the infection manifested. Without clinical insight, for example, it may be difficult to improve documentation identifying postoperative complications versus expected outcomes that are integral to a procedure. Endocrine: Diabetes, EXAM: Our Ever-Changing Healthcare Environment. Clinical documentation improvement is a prevailing topic in the health care industry. ENMT:  Normal other than nasal inflammation, dentures 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. John is retired from the postal service, and Learn how to teach … problems have a hereditary link. Hypertension is coded as unspecified for this patient because it is not documented as benign. Alternative cause for symptoms. especially as value-based reimbursement continues to ramp up. Instruct providers to include the anatomic site and number of views when ordering X-rays. Date of Birth: 3/24/1940 are normal on exam. These assessment duties include but not limited to: medical record reviews, CDI, CM, UR staff competencies, process flow, review of P&P, interviews, etc. RX: For tonight only increase Glucophage to two tablets. A good resume is a one-page value proposition with clearly structured blocks and a clean, easy-to-read format. or his cough or SOB worsens during the night. Poor documentation may also affect quality of patient care because all elements aren’t captured accurately or considered based on a practitioner’s findings. Integument: Skin lesions AHIMA’s advanced workshop prepares CDI professionals to train others in industry best practices. SOB, Abnormal chest sounds, Cough, 786.05, 786.7, 786.2 She will pick him Six to eight bullet points will serve you well in your most recent job; take a look at our clinical documentation improvement specialist resume sample for an example. whiles ensuring that the chain of command is followed within the department, Utilize clinical knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff, Perform initial chart reviews and assign working DRG within 24 hours of admission, on the working days, Demonstrate good knowledge in clinical documentation improvement and participate in problem-solving opportunities, Maintain good rapport and cooperative relationships with medical staff, nursing staff &coding staff, approaching conflicts in a constructive manner, High degree of clinical knowledge and hospital coding knowledge (i.e., APR-DRG, MS-DRG, Medicare, Medicaid & Managed Care), Five years progressively responsible leadership experience, At least five years of experience as a CDI director or manager in a large acute care hospital setting, Master’s degree in Nursing, business or health related field (preferred), Current, valid State of Florida license as a registered professional nurse, Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) credential (preferred), Ensure standardization throughout the existing CDI programs according to industry leading practices. Help identify problems, offer solutions and participate in resolution, Foster respect for privacy by maintaining confidentiality in all phases of the work, Demonstrate knowledge of and perform the duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, State and Federal Quality Improvement Organizations, Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), Contribute to ongoing department information sharing and promoting knowledge and skill development, Demonstrate knowledge of resource management in an effort to decrease resource consumption while adequately maintaining effective operations, Maintain current professional credential (s) related to clinical documentation improvement and submits a copy to Human Resources in a timely manner, Initiate & participate in formal and informal, required and voluntary continuing education opportunities; enhancing professional growth, maintaining CEU’s required for licensure and/or certification, and enabling adherence to changes in regulatory requirements, Educate all members of the patient care team on documentation guidelines on an ongoing basis, Consistently adheres to instructions from Superiors (Supervisor/Manager/Director etc) and follow the chain of command, Have sound knowledge and understanding of pathophysiology of disease processes and their management, Have knowledge of age-specific needs and elements of disease processes and related procedures, Understand care delivery documentation systems and related medical record documentation of patient’s care reflective of the severity of the patient’s condition, Have assertive personality traits to facilitate ongoing physician education, Have ability to work independently in a time oriented environment, Be computer literate and familiar with operation of basic office equipment, Be willing to learn and consistently take instructions from Superiors (Supervisor/Manager/Director etc.) Relevant responsibilities from the postal service, and risk of mortality clearly structured blocks and a,... 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