Orlando Health Orlando , FL 32801
Posted 2 weeks ago
Position Summary
Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures.
This is a hybrid position, hospital will be Arnold Palmer Childrens Hospital
Qualifications
Education/Training
Graduate from an approved school of nursing.
Licensure/Certification
Maintains current State of Florida RN license or valid eNLC multistate RN license.
Experience
Three (3) year acute care hospital experience required.
Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital
setting.
Responsibilities
Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical
record for accurate reflection of the acuity of the patient and justifying the level of care.
provided.
thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS
worksheet. Determines the appropriate principle diagnosis of the patient.
rating purposes.
Documents findings in workflow tools, noting all key information used in the tracking process.
Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical
record.
Uses appropriate querying tools (templates) to capture needed documentation.
Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician
documentation that supports the patient condition(s) and treatment plan Provides education to physicians on the importance of
complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.
focus through report analysis.
and local standards.
Education/Training
Graduate from an approved school of nursing.
Licensure/Certification
Maintains current State of Florida RN license or valid eNLC multistate RN license.
Experience
Three (3) year acute care hospital experience required.
Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital
setting.
Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical
record for accurate reflection of the acuity of the patient and justifying the level of care.
provided.
thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS
worksheet. Determines the appropriate principle diagnosis of the patient.
rating purposes.
Documents findings in workflow tools, noting all key information used in the tracking process.
Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical
record.
Uses appropriate querying tools (templates) to capture needed documentation.
Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician
documentation that supports the patient condition(s) and treatment plan Provides education to physicians on the importance of
complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.
focus through report analysis.
and local standards.
Orlando Health