The Documentation Specialist improves the overall quality and completeness of clinical documentation. You will interact with physicians, nursing staff, case management and medical record coding staff to facilitate modifications to clinical documentation that ensures accurate depiction of the level of clinical services and patient severity. On an ongoing basis you will educate all members of the patient care team, provide education programs as required and participate in select committees. You will review the quality of medical record documentation in selected diagnostic categories and identify and convey deficiencies to house staff and attending physicians.
1. Reviews clinical documentation and facilitates modifications (as needed) to ensure that documentation accurately reflects the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients.
- Maintains a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions.
- Initiates chart review within 24-48 hours of admission to meet criteria.
2. Monitors, systematically, the targeted medical records (at least every 48 hours unless otherwise indicated) to determine compliance to established documentation standards.
3. Notifies attending physicians and house staff officers or other disciplines promptly of chart deficiencies requiring clarification, with a preference for face-to-face communication where practicable.
4. Conducts follow-up reviews to ensure points of clarification have been addressed/recorded in the patient chart.
- Maintains an ongoing record of the results of each chart review including responses to all interventions.
5. Reviews the medical record post discharge to determine coding status.
6. Compiles and provides timely statistical reports including, but not limited to:
- Number of charts reviewed
- Number of charts with documentation deficiencies per physician
- Final DRG assignments
- Other pertinent data
7. Facilitates the ongoing education of staff in chart documentation improvement techniques and practices.
- Provides periodic formal and informal in-service updates to medical staff and other disciplines using both one-on-one and group forums.
- Educates practitioners on a one on one basis.
- Develops and disseminates documentation improvement literature in conjunction with Medical Staff.
8. Serves as a resource to Physicians / Case Managers and other key professional staff in matters relating to published DRG information.
9. Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.
- Bachelor's Degree in Nursing or related field, required. Master's Degree, preferred.
- Currently licensed and/or registered as a Professional Nurse or Physician Assistant in the State of New York, required.
- Minimum of five (5) years of progressive clinical experience in an acute care setting. Previous experience in chart review, required. Regulatory background and DRG reimbursement knowledge preferred.
- Ability to communicate effectively with physicians and other clinical professional staff.
** MUST be a Registered Nurse with a BSN**
Transforming care, optimizing patient satisfaction and creating better patient outcomes are just some of the things our talented team members are doing at North Shore-LIJ each and every day. As a culture committed to providing out customers with the highest quality service, we stand behind out core values: Patients first; Caring, Excellence; Innovation; Integrity and Teamwork. It is our commitment and our culture that sets us apart from others and is the cornerstone of everything we do. Join an organization whose team members are valued, cared for and offered continuous opportunities to grow. Click on the link to learn more about us: www.northshorelij.com/goals
Please note: North Shore-LIJ is a smoke-free environment. Smoking and the use of tobacco products is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises. Free smoking cessation programs and quit medications are offered to team members who wish to quit through the North Shore-LIJ Center for Tobacco Control.