What are the responsibilities and job description for the Clinical Documentation Specialist- Health Information Services position at Beaufort Memorial?
Description
This position is responsible for performing concurrent review of the clinical documentation in the medical record. These duties include but are
not limited to :
- Using clinical judgment and clinical analytical skills, queries the medical staff and other care givers through written and verbal communication to obtain accurate and complete documentation that supports the severity of patient illness and risk of mortality, as well as allowing accurate assignment of ICD-9-CM codes that reflect the highest level of specificity that supports treatment provided.
- This includes querying for physician intent to assure identification and documentation of all co-morbidities and complications.
- Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.
- Uses clinical decision-making to identify 'hints and clues' in the chart that would guide the physicians documentation toward clearly defined definitive diagnoses rather than non-specific signs and symptoms.
- Demonstrates creativity and enthusiasm while pursuing departmental and organizational goals.
- Maintains the ability to be flexible and prioritizes daily responsibilities.
Position Requirements
Education :
Experience :
Certifications / Licenses :
