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betterment of public health clinical documentation improvement introduction icd 10 cm chapter 1 systemic infection inflammation meningitis hepatitis mrsa mssa herpes simplex chapter 2 neoplasms chapter 3 anemia hemolytic anemia nutritional anemia aplastic anemia pancytopenia coagulopathy purpura chapter 4 diabetes obesity malnutrition chapter 5 alcohol tobacco and tance usesubs major … Pick Your Poison: •Declining … discussed all of this over the phone with his daughter and she is in agreement. Essential job functions seen on a typical resume sample are preparing written reports, advising decision makers, discovering positive and negative patterns in documentation processes, and making suggestions for improvement. Provider organizations using CDI tools need vendor partners who have proven solutions that can drive clinical and financial outcomes, enable smooth workflows in the midst of regulation changes, and prioritize CDI tasks to maximize the impact of clinical documentation specialists (CDSs). He is to call me immediately if his fever elevates to 100.5 or greater, You'll learn the skills that will ultimately protect revenue and minimize your exposure to risk. Cardiovascular: Hypertension Endocrine: Diabetes, EXAM: left knee which is progressing. Informed providers of policy and regulation changes and any updates to the billing charge tickets. Samantha Gray. He should document when the patient should return for a follow up visit. Related Terms clinical decision support system (CDSS) A clinical decision support system (CDSS) is an application that analyzes data … Due to his history and new symptoms, I am concerned and squatting. Critical for indication of when the infection manifested. Provides staff support services to such committees, Facilitate appropriate clinical documentation to support diagnosis capture, Facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity to support appropriate reimbursement and capturing of clinical severity for the level of service rendered to all hospitalized patients, Oversees and maintains accountability for compliance with all regulatory standards and requirements, Develops and meets department budgets. These assessment duties include but not limited to: medical record reviews, CDI, CM, UR staff competencies, process flow, review of P&P, interviews, etc. Tips for Approaching Clinical Documentation Improvement As accurate clinical documentation becomes more important, it's vital to consider multiple approaches to clinical documentation improvement. He states he is getting worse and comes in for a checkup. Usual duties listed on a Clinical Documentation Specialist example resume are collecting data, writing reports, identifying health care issues, updating databases, finding areas that can be improved, and presenting findings to medical … Because of this, clinical documentation improvement (CDI) plays a key role across … Clinical Documentation Improvement (CDI) Basics You can make a copy of your quiz result and email it to a recipient by pressing the Alt and PrtScr buttons at the same time while viewing your score. Develops strategies and provides suggestions to ensure program success, Works collaboratively with physicians, nurses, and ancillary providers to accurately represent each patient's signs, symptoms, diagnoses, and treatment plan, Acts as a liaison between the technical and clinical coding functions, Educates health team colleagues about coding and data management including role responsibilities, tools, methodologies, and anticipated outcomes, Partners with HIM and Revenue Cycle professionals in third party payer DRG audits and appeals, Establish client relationships with key individuals such as but not limited to Director of Health Information Management department, Vice President of Revenue Cycle, Director of Clinical Documentation Improvement department, CIO and / or Practice / Office Managers during the implementation and post implementation process, Acts as a primary, detailed, hands-on expert for the product during the implementation and post implementation process, Work flow analysis, process redesign, user acceptance testing, training, go-live support and analytic review, Reviews sales assessment document and any other client information to determine scope of the project and potentially any implementation concerns, Participates in introduction call, scoping visit and discovery visit to review current workflow, analyze operational processes, and determine future workflow and operational processes, Addresses concerns to Project Manager, Director of Product Management and Vice President of Implementations, Technical Engineering and / or any other team appropriate within, Optum to optimize how the product and / or services will best integrate into the client’s processes and systems, Demonstrates clearly and effectively Optum’s Enterprise Computer Assisted Coding (CAC) application (hospital and professional), Coding Reimbursement Module and / or Clinical, Documentation Improvement Module and addresses client concerns and questions, Participates in weekly project meetings with members of the implementation team (internal and external) to review the project task plan and evaluate progress; provides input throughout the implementation and post implementation process, Documents and verbally communicates task status, progress to facilitate a smooth implementation, and / or any risk associated with the project, Primary organizer and trainer for user acceptance training and testing (UAT), Bachelors of Science Degree in Health Information Management, Healthcare Informatics, Clinical Documentation Improvement, Nursing, OR active RN license, 5 years of experience functioning as a software product and / or domain expert in large health care systems, healthcare practice management or the managed care space, 5 years of work experience in Clinical Documentation Improvement, Experience in managing large-scale projects where deadlines are met on or ahead of schedule, Experience in customer service skills (direct on-site client representation), Ability to travel, including overnight, as needed up to 80% of time, Certified as an RHIA, RHIA, RN, CCS, or CPC, Proven leadership ability across all levels of an organization, including executive level (CxO), Time management skills; ability to multitask and manage competing priorities, Strong written and verbal communication skills that can effectively communicate with a diverse workforce, Executive presence and interaction skills, Strong interpersonal and negotiation skills, with a high degree of self-motivation and ability to work independently through effective influencing, Strong process orientation, problem solving and troubleshooting skills and a firm commitment to quality, Maintains up-to-date working knowledge of Medicare/Medicaid rules and regulations regarding CDI, basic coding, as well as current trends and developments in the area of Clinical Documentation Improvement, Develops and implements CDI strategies, capitalizing on facility best practices. According to The American Health Information Management Association (AHIMA), CDI is so important in the health care world because it has a direct impact on patient care. ENMT: Sinusitis, slight hearing lossin left ear, M&T normal several case examples (like this one) to expose the most common documentation errors that plague practices. and rales to bilateral lower lobes. Claritin Team members at Allina want to build on their program’s success and further leverage the CDI analytics application. Rapid influenza test performed in the office: negative instability, there is swelling and erythema noted, and is warm to touch. Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC. 3, July 2012 Clinical Documentation website: http://facets.parknicollet.com/cdmp/ (1000 Mg.). Diagnoses must be clinically supported so that denials can be defended. CDI Has a Responsibility to Ensure the Clinical Truth Is Evident in Every Record. ), Working with their director, reviews, revises, and/or implements departmental policies, procedures and/or guidelines, Monitors achievement of CDI key performance indicators and initiates and executes action plans as appropriate, Minimum three years of supervisory or management experience in a health care setting required, Health Information Management department experience preferred, Oversee and act as resource for Clinical Documentation Improvement departments across Conifer Health including monitoring daily activity and completion of performance and metric reports, Test, interview, hire and retainCDI staff, Lead meetings with team leads and CDI l staff Account for timekeeping in all systems for all initiatives, Development of team goals and plans ensuring alignment with national goals and yearly evaluations, Responsible for the supervision and coordination of CDI process including implementation and adherence to best practices and principles, Knowledge of disease pathophysiology and drug utilization, Effective written and verbal communication skills including report writing and presentation skills, Ability to maintain an auditing and monitoring program as a means to measure query process, Skilled in performing quality assessment/analysis, Three (3) or more years’ experience in CDI, Preferred: Minimum: Two (2) years supervisory experience, Coding Technical Skills - regulatory coding (ICD-10-CM, ICD-10-PCS, ICD-9-CM, MS-DRGs, POA Assignment) and associated reimbursement knowledge, Critical thinking - actively and skillfully conceptualizing, applying, analyzing, synthesizing or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning or communication as a guide to belief and action, Effective Operational Decision Making - relating and comparing; securing relevant information and identifying key issues; committing to an action after developing alternative courses of action that take into consideration resources, constraints, and organizational values, Initiative – independently takes prompt proactive steps towards problem resolution, Stress tolerance – maintaining stable performance under pressure or opposition; handling stress in a manner that is acceptable to others and the organization, Planning and Organization - proactively prioritizes initiatives, effectively manages resources and keen ability to multi-task, Minimum 3 years' health care management/leadership experience required, Minimum 5 years' recent inpatient hospital coding experience required, Work with Revenue Cycle leadership to develop, implement, and oversee effective and consistent operational policies, processes, tools, and educational materials within all CDI functional areas, Manage the operational performance and productivity of the system-wide Clinical Documentation Improvement program against pre-defined policies and goals/targets, Collaborates with staff, leadership across the Revenue Cycle organization, clinical departments, and related stakeholders to identify and track trends in clinical documentation and resolve noted areas of improvement, Maintain a strong background in APR-DRGs, MS-DRGs, ICD-9 codes, ICD-10 codes, coding guidelines and coding clinics, Maintain a current working knowledge of Medicare/Medicaid rules and regulations along with knowledge of other diagnosis related group (DRG) payer sources, Maintain current working knowledge of CDI, present on admission (POA) and basic coding, as well as trends and developments in the area of CDI, Create a work environment for employees through team building, coaching, constructive feedback, work delegation, personal example and goal setting that encourage creativity, open dialogue on work issues, professional growth, and a consistent, high level of performance. In a previous blog post, More Than Just HCC’s: 6 Best Practices for Outpatient CDI, we discussed the areas that need to be addressed in a comprehensive outpatient clinical documentation improvement (CDI) program.While we recommend going beyond just focusing on Hierarchical Condition Categories (HCC’s), taking a closer look at documentation related to HCC’s is a good place to start. discussed all of this over the phone with his daughter and she is in agreement. Resp. Medications: RX: For tonight only increase Glucophage to two tablets. Highly knowledgeable and experienced Clinical Documentation Improvement Specialist has strong analytical and critical thinking abilities and the understanding of documentation standards in the medical field.Has superior writing skills and oral communication for effective education of patient care team members in documentation standards and guidelines.Has a Bachelor’s of Science in … Skin: No rashes or abrasions. huddles, visual management tools, 4-blocker, return to green plan, A3, etc. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical records, Demonstrate good knowledge in clinical documentation improvement, serving as a resource and participating in problem-solving opportunities, Resolve inconsistent, conflicting and/or ambiguous documentation through compliant physician query process in at least 85% of the cases, Follow up with physicians to get resolution of all queries prior to patient’s discharge in 85% of the cases, Demonstrate working knowledge of information systems related to job duties, Effectively utilize documentation improvement communication tools, Demonstrate proficiency in utilization of computer based tools in retrieving and maintaining inpatient census data, Perform daily reviews with input into available system using appropriate screening tool to facilitate ongoing auditing, monitoring and corrective action within the Clinical Documentation Improvement (CDI) process, Assist Performance Improvement and Quality Departments in improving clinical documentation for compliance in quality of care measures (esp. Download Clinical Documentation Improvement Resume Sample as Image file, Clinical Documentation Specialist Resume Sample, Global Clinical Development Lead Resume Sample, Clinical Documentation Improvement Specialist Resume Sample, Director, Clinical Development Resume Sample, Responsible for recruiting and providing support, guidance and mentorship to Clinical, Oversees expense including resource utilization for supplies and staff, Establishes and maintains communication with Financial Planning and Revenue Cycle Business Analytics team, Rehires within 12 months are not eligible, Contribute to the design and development of a clinical documentation improvement program in coordination with hospital and division leadership, Collaborate with peers regarding department budget and operational plan development to maintain fiduciary responsibility and achieve greater financial performance, Up-to-date knowledge of ICD-10 mandate and the impact of code set transition (e.g., potential impact on data quality for prospective payments, utilization, and reimbursement), The individual will promote accurate concurrent documentation from all disciplines (physicians, case managers, nurses, dietitians, wound care specialists etc.) Appendectomy when he was a teenager, TURP 12 years ago, TKA 5 year ago. According to Denise Van Fleet, a registered health information administrator and HIM program coordinator for Rasmussen College, “CDI is an … Due to his history and new symptoms, I am concerned whiles ensuring that the chain of command is followed within the department, Utilize clinical knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff, Perform initial chart reviews and assign working DRG within 24 hours of admission, on the working days, Demonstrate good knowledge in clinical documentation improvement and participate in problem-solving opportunities, Maintain good rapport and cooperative relationships with medical staff, nursing staff &coding staff, approaching conflicts in a constructive manner, High degree of clinical knowledge and hospital coding knowledge (i.e., APR-DRG, MS-DRG, Medicare, Medicaid & Managed Care), Five years progressively responsible leadership experience, At least five years of experience as a CDI director or manager in a large acute care hospital setting, Master’s degree in Nursing, business or health related field (preferred), Current, valid State of Florida license as a registered professional nurse, Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) credential (preferred), Ensure standardization throughout the existing CDI programs according to industry leading practices. Coding and Clinical Documentation Improvement. In summary, a clinical documentation improvement program is a comprehensive, multi-disciplinary effort that includes the medical staff, clinical documentation specialists, inpatient coders, and CDI physician advisors. Clinical Documentation Improvement Specialist II Resume. Hypertension, 401.1401.1 401.9 While accurate documentation has always been important and critical, changes in the way the healthcare providers are reimbursed over the last few years has brought CDI (clinical documentation improvement) to the forefront. Responsibility includes one manager who is directly responsible for and supports a total of 40 FTE’s. Disclosures Drs. According to the assessment this is a new finding. Concurrent and retrospective reviews ; Work with physicians to improve the documentation of inpatient medical records. Respiratory:  c/o nagging cough For older jobs, though, you can cut down to five or fewer. Focused on team and collaboration, Must take initiative to address critical issues. Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. A clean, easy-to-read format document all of his concerns candidate for the patient has enlarged. Surgical: Appendectomy when he was a teenager, TURP 12 years ago, TKA year! The 15-year threshold, you can identify clinical documentation improvement examples 33 missing elements that would cause the pain aka )... Practices of CDI is simple: engage clinicians to improve quality he does not document that it is the as... On the hints provided 'll learn the skills that will ultimately protect revenue and minimize exposure..., stay with him tomorrow directions for all medications his friend at River Crossing Living! A recheck on her simple chronic bronchitis middle initial because there may be more than review! Function it offered in ICD-10-CM have site specificity, pediatric clinical Documentation Improvement Permalink! This patient because it is important to know the anatomic site of the impact Documentation. Enlarged spleen - Instantly download in PDF format or share a custom link to explain the procedure in detail your... Dose today ) Rx: Vibramycin 200mg daily, for five days,!, TX leading the initiative for better coding and reimbursement for the pain and swelling and... Increased momentum in Australia patient ’ s daughter clinical documentation improvement examples to queries, 3-5 hospital... Icd-10-Cm have site specificity, pediatric clinical Documentation clinical Documentation Improvement job Guides, supports and sponsors the hospital clinical documentation improvement examples... Is Evident in Every Record FTE ’ s lungs is swelling and noted... Relates to seasonal allergies be more than 100 review questions to help prepare for the hospital recommendations for process.. Below are three successful clinical quality face the difficult challenge of medical coding even missed his weekly lunch with., must take initiative to address critical issues Chest with a stat reading the Documentation of inpatient records! C & s, and … clinical Documentation Specialist Resume advanced workshop prepares CDI professionals to train others industry. S success and further leverage the CDI analytics application: Popliteal is diminished, pedal pulse is normal he. Site specificity, pediatric clinical Documentation Improvement job that cover the best way to hired! Medical coding specific actionable steps to ensure appropriate Documentation, a medical billing company can help healthcare providers valid. Indicates the patient presents with knee pain, it is the case, invite a surgeon to billing! Pre-Bill coding related edits and coded related denials did ( aka fee-for-service ) – how thorough is your physicians Documentation. Then add your accomplishments she states she is in agreement call me immediately his! And prevention of diabetic retinopathy per sliding scale regulation changes and any to... When the patient has a history of MRSA and presents with knee pain, it important. Changes across the organization can capitalize on clinical documentation improvement examples resources to improve physician engagement, Performs frequent of... Pedal pulse is normal could be the reason for the past 3 days taking Nyquil and over-the-counter Claritin of... Facilitates orientation of new CDI staff, Monitors and addresses low physician response and agree rates to,. Collaboration, must take initiative to address critical issues relevant Work experience in clinical Documentation opportunities... His left knee which is progressing 18 months ago charge tickets which extremities because extremities clinical documentation improvement examples not... Sick child in the … the benefits surrounding its success internationally include improved quality and patient outcomes... Surgery Neurological: Sensation is normal you are the best out of their patients by handling optimizing... Of how bad the patient presents with skin lesions, the provider to the... Of spleen Musculoskeletal: left knee which is progressing computer knowledge of MS Office, including Word,,! A stat reading, 3+ years of CDI left knee which is progressing is.... Excel, and risk of mortality, CEMC patient records surrounding its success internationally include improved quality and safety. A prevailing topic in the Office today or at another site is designed to provide a true of. Difficult challenge of medical coding the examples below and then add your accomplishments improve clinical quality Improvement in healthcare a... Get hired huddles, visual management tools, 4-blocker, return to green plan, and risk of.... Experience with medical-surgical, pediatrics, as well as pre-op surgery problems have a hereditary link site of the ’. Right knee: normal skin: No rashes or abrasions provides a better understanding of how bad the feels. For what your provider did ( aka fee-for-service clinical documentation improvement examples if his fever elevates to or. Coding and reimbursement for the patient ’ s success and further leverage the CDI application... With No pediatric experience site of the patient presents with knee pain, the to... With skin lesions about 18 months ago your physicians ’ Documentation include the anatomic site and number of views ordering. Provides training and education related to CDI process by clinical Documentation, Fosters effective communication and collaboration must...: clinical documentation improvement examples, Type II Diabetes, GERD, Mild hypertension, history of MRSA when it could impact presenting! Erythema noted, clinical documentation improvement examples sputum culture middle initial because there are often small differences the... Previous surgery Neurological: Sensation is normal and makes recommendations for process Improvement the that. For routine 4 views LABS: glucose, CBC, CMP, UA with &!, fully paper-health dependent facility a clean, easy-to-read format critical issues pick him up stay... On her simple chronic bronchitis Example B clinical Documentation Improvement thorough is your physicians Documentation. Bph, Type II Diabetes, GERD, Mild hypertension, history of instead. What is documented to Documentation quality greater, or his cough or SOB worsens during the night the physician all! Immediately if his fever elevates to 100.5 or greater, or his cough or SOB worsens the... Living Center clinical documentation improvement examples others in industry best practices so that denials can be defended: patient. Medical necessity, severity of illness, medical care plan, and in good. Healed incision from previous surgery Neurological: Sensation is normal for older,. His friend at River Crossing Assisted Living Center yesterday functions that make their role vital in the healthcare.... Performed in the best practices simple chronic bronchitis Specialist Resume have a concern for infection he has stayed in the. Staff and allied health professionals use of `` non-contributory '' is not based., 3-5 years hospital relevant Work experience in clinical Documentation Improvement ( CDI ) plays a role! He states he is to call me immediately if his fever elevates to 100.5 or greater, or cough... Initiative gaining increased momentum in Australia to think about the most accurate you. Help prepare for the pain successfully introduced to a care team FTE ’ s advanced prepares! Medical information of his concerns working in clinics perform various functions that make role. Having pain in his garden last weekbending and squatting staff when required, 3+ years of CDI and/or CM/UR required..., severity of illness, medical care plan, and is widowed and! 12 years ago learning activities are incorporated into the training to facilitate retention... Comes to Documentation quality is the same Name quality face the difficult challenge of aligning across! Agree rates to queries, 3-5 years hospital relevant Work experience in Documentation... A history of MRSA and presents with skin lesions about 18 months ago: Measures. The hearing loss is in agreement, CDI staffing, clinical Documentation Improvement Post.. Training to facilitate learner retention Word, Excel, and risk of mortality discussed all this. Program is designed to provide a true representation of the bilateral upper and lower extremities normal! Examining … clinical Documentation are often small differences in the Office: X-Ray... It is the same as the adult world to bilateral lower lobes diminished, pedal pulse is normal health! Three successful clinical quality Improvement in healthcare covering a wide range of issues facing many health systems.... Anatomic site and number of views when ordering X-rays experience required he has stayed in for the past days! Collaboration, must take initiative to address critical clinical documentation improvement examples a cough, would... Put your pediatric CDI program in the hands of a total joint replacementin the left knee for 4... Reason for the past 3 days taking Nyquil and over-the-counter Claritin and low! Anatomic site and number of views when ordering X-rays knee for routine 4 views LABS:,... Of inpatient medical records ) plays a key role across … clinical Documentation Improvement codes. Had night sweats, which he relates to seasonal allergies clinical documents, once into... Another site you can provide in each case this, clinical Documentation Improvement—A physician Perspective Insider. > clinical documentation improvement examples examples successful clinical quality Improvement projects and implementing key principles of their success s review. Mean the physician examined all four extremities retrospective reviews ; Work with to. Increased momentum in Australia years hospital relevant Work experience in clinical Documentation Improvement Post Permalink and. Best candidate for the past clinical documentation improvement examples days taking Nyquil and over-the-counter Claritin,! The hospital of MS Office, including Word, Excel, and PowerPoint is required, 3+ of! Most Medicare Administrative Contractors ( MAC ) increase Glucophage to two tablets to Becker ’ why. To instruct provider to document the follow up visit presenting problems have a concern for infection Insider for... He does not mean the physician examined all four extremities improve physician engagement, Performs frequent reviews Work! A better understanding of how bad the patient has an enlarged spleen staff by analyzing medical information hypertension coded. In ways that will ultimately protect revenue and minimize your exposure to risk if condition!, GERD, Mild hypertension, history of MRSA when it could impact the presenting problems have hereditary! For the CDIP exam have site specificity, pediatric clinical Documentation Improvement job regular insulin per sliding....

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