Clinical Documentation Registered Nurse II - Document Integrity

Clinical Documentation Registered Nurse II - Document Integrity at Christus Health summary:

The Clinical Documentation Registered Nurse II enhances the quality and completeness of medical records by reviewing inpatient documentation and collaborating with physicians and coding staff. They ensure accurate DRG assignment and proper reimbursement by identifying gaps, educating clinical staff, and maintaining documentation tools. This role requires clinical expertise, communication skills, and compliance with healthcare regulations to improve clinical documentation integrity.

Summary:

This position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records. The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.

Responsibilities:

• Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
• Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation
• Maintains positive open communication with physicians, nursing and all other disciplines involved in the care of the patient
• Works closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care
• Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures
• Updates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosis
• Consistently meets established productivity targets for record review
• Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation
• Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies
• Assists in collection and organization of data for analysis by appropriate medical and hospital committees
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation
• Demonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the department
• Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served
• Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities
• Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties
• Performs other duties as assigned

Requirements:

• Associate's Degree in Nursing
• RN License in state of employment or compact

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time

Keywords:

Clinical Documentation, Registered Nurse, Medical Records, DRG Assignment, Physician Communication, Health Information Management, Patient Care Documentation, Clinical Review, Reimbursement Documentation, Healthcare Compliance