Clinical Documentation Specialist
CurrentPerform concurrent in patient EMR (electronic medical record) reviews to define areas of improvement in health care provider documentation. Request additional documentation from the health care provider with written and verbal communication that support the clinical indicators, risk factors and treatment identified in the review of the EMR that will capture the severity of illness and risk of mortality for each patient encounter. Also, identify and seek clarity for conflict in documentation, specificity of disease process and completeness of required documentation in order to meet medical necessity, hierarchical conditions, address possible patient safety indicators as well as hospital acquired conditions so the chart will be coded correctly at the time of discharge.
