POSITION SUMMARY

The Clinical Documentation Specialist monitors the quality of medical records and document by abstracting data, entering multiple stroke and research databases and ensuring quality improvement of data collection on stroke performance metrics and nursing metrics. This also includes assuring the medical records contain the mandated core measure data used to report to multiple regulatory agencies. The Clinical Documentation Specialist facilitates concurrent modifications to clinical documentation to ensure adequate information is included in the medical record about diagnosis, treatment, and follow-ups. They communicate and educate physicians, nurses, coding staff and other healthcare professionals to clarify issues and assure missing information is included to meet policies and regulations. They assist with clinical research recruitment, consenting, data collection, abstraction, and follow-up for clinical research trials.

ESSENTIAL JOB FUNCTIONS AND CORE RESPONSIBILITIES

Education

Assists nursing staff in preparation for DNV survey and post survey findings.Concurrently reviews a patient's medical records to ensure documentation is accurate as well as up to date with the latest information on a patient's diagnosis and educates staff on any missing documentation elements. Following up with doctors and nurses where needed to complete an individual patient’s records.Coaches and mentors’ staff to ensure optimal outcomes.Provides staff education as required by LA County EMS, DNV and the American Stroke Association.Partners with stroke team to develop patient education resources and provides nurses support with providing stroke patient education.Participates in stroke education/training for members of the healthcare team, including stroke scales, stroke protocols and guidelines, best practices, and emerging treatments.Collaborate and participate in stroke prevention community outreach efforts.

Clinical Practice and Collaboration

Provides ongoing patient follow-up calls post discharge with the goal of improving quality of life for the patient and prevention of readmissions to the hospital.Conducts 7-day stroke patient satisfaction calls post discharge.Conducts 90-day follow-up calls for patients that receive neuro intervention and calculation of Modified Rankin Scale (MRS)Collaboration with physicians and personnel from all departments and specialty areas to optimize stroke care in accordance with stroke guidelines.

Quality Improvement and Data

Assistance with post survey auditing and metrics.Data abstraction, entry and submission to Get with The Guidelines Stroke.Design, build and generate reports from data abstracted from patient records.Provide more complex information for documentation changes to assure core measures are met.Demonstrate proficient use of excel and other databases needed to store and abstract data.Recognizes opportunities for improvement by using strong critical-thinking skills. Uses critical thinking, clinical experience and sound judgement to adjust documentation to meet regulatory requirements.Initiates chart review audits to validate quality outcome data for nursing and stroke program metrics.Collaborates with Stroke Medical Director, Stroke Coordinator, Stroke Navigator and Clinical Research Manager to initiate performance improvement initiatives to improve processes that will ultimately improve care.Performs other duties as assigned.

Clinical Research

Identifies patient eligibility for available research studies.Collaborates with the Clinical Research Team in consenting patients for research studies.Oversees documentation for the stroke patients assuring consistency, accuracy to meet clinical research and regulatory requirements.

Physicians as Partners

Demonstrates effective communication and behaviors that support teamwork in a professional manner.Works with the Stroke Program Medical Director and stroke team to continue to improve our overall patient care.Acts as a role model and leader in addressing physician issues and concerns.Promotes interdisciplinary coordination of patient care.Ensures that patients' needs are being met and patients/families are satisfied with the care they are receiving.

Education Minimum (Required) Bachelor’s degree in nursing required. Licenses and Certifications Minimum (Required) • A current RN licensure in the State of California required. • ACLS certification required when appropriate. • BLS certification required. • CITI- Human Subjects Training, Good Clinical Practice, GCP for Clinical Trials with Investigational Drugs and Biologics, Biomedical Human Subjects and Device. • MRS (modified Rankin scale) certified. • NIH Stroke Scale Certified.