Improves overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity through extensive concurrent interaction with physicians, nursing staff and other caregivers, case management and medical records coding staff. Reviews quality of medical record documentation in selected diagnostic categories. Identifies and conveys deficiencies to house staff and attending physicians. Compiles and reports chart review findings, periodically. Educates all members of patient care team on an ongoing basis. Participates in select committees and provides education programs as required.
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 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, preferred.
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.