Clinical Documentation Registered Nurse II - Document Integrity
- 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
- Associate's Degree in Nursing
- RN License in state of employment or compact
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