The Clinical Documentation Specialiist (CDS) professionals strive to promote an accurate and meaningful database that clearly demonstrates the resources used in the patient's care. The CDS is an essential resource to the clinical team and collaborates extensively with Physicians/Providers, HIM coding team, Nursing, Patient Management, Quality Department and ancillary staff to perform concurrent analytical review of clinical documentation and coding data.The CDS facilitates obtaining appropriate clinical documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The goal is to improve documentation of all conditions and treatments from point of entry to discharge,ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, documentation/coded quality metrics, and reimbursement. The CDS exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and/or procedures. They educate members of the patient care team regarding clinical documentation guidelines and impact, including attending Physicians, Advanced care practitioners, Residents/Medical students, Business Advisor's and other members of the health care team. The CDS is also responsible for audit review to identify potential documentation deficiencies in specific records and to identify clinical specialties that require focused interaction and physician/provider education.
**Buffalo, NY**