Using a multidisciplinary team approach the Quality Documentation Specialist facilitates and obtains appropriate clinical documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. A diverse clinical background and in depth knowledge of pathophysiology is a must. With training, exhibits a detailed knowledge of clinical documentation requirements, DRG assignment, as well a firm understanding of coding guidelines. The CDIS educates members of the patient care team regarding clinical documentation guidelines, including attending physicians, allied health practitioners, and nursing. Reviews medical records concurrently on a daily basis to identify opportunities to improve the quality and completeness of clinical documentation. Facilitates modifications to clinical documentation when appropriate, through extensive concurrent interaction with physicians, mid-level providers, HIM staff, allied health professionals and nursing staff to support accurate, complete and timely documentation of clinical information in the electronic patient record. Coaches and educates physicians, mid-level providers, HIM staff, allied health professionals and nurses on a daily basis to improve capture of clinical severity for the level of service rendered to patients.
Educational Requirements Degree/Diploma Obtained Program of Study Required/
Preferred and/or Bachelor's Required Additional Requirements Experience Requirements Minimum Years Required Area of Experience Required/
Preferred and/or 5 Years Clinical Nursing Required State of Florida Licensure Requirements Licenses Required/
Preferred and/or Registered Nurse License Required Certifications/Registration Requirements Certificates/Registrations Required/
Preferred and/or CCDS (Certified Clinical Documentation Specialist) Preferred Additional Requirements required
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