Clinical Documentation Registered Nurse II - Document Integrity at Christus Health Beaumont, TX

Clinical Documentation Registered Nurse II - Document Integrity

Christus Health – Beaumont, TX.

Description

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.

• Analyze the clinical status of the patient, current treatment plan and past medical history and identify potential gaps in physician documentation.
• Communicate with attending physicians verbally or through written methodology to validate observations and suggest additional and/or more specific documentation.
• Maintain positive open communication with physicians, nursing and all other disciplines involved in the care of the patient.
• Work closely with HIM Coding staff to assure documentation of discharge diagnosis and any co‑existing co‑morbidity are a complete reflection of the patient’s clinical status and care.
• Maintain an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures.
• Update the DRG worksheet to reflect any changes in inpatient status, procedures or treatment and confer with the physician to finalize diagnosis.
• Consistently meet established productivity targets for record review.
• Design and implement, in collaboration with physician leadership, specific tools to support medical record physician documentation.
• Develop and implement 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.
• Assist in collection and organization of data for analysis by appropriate medical and hospital committees.
• Identify strategies for sustained work‑process changes that facilitate complete, accurate clinical documentation.
• Demonstrate competence to perform assigned responsibilities in a manner that meets the population‑specific and developmental needs of the members served by the department.
• Appropriately adapt 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.
• Perform 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.
• Perform other duties as assigned.

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

8:00 a.m. – 5:00 p.m., Monday‑Friday.

Full‑time position.