Clinical Documentation Registered Nurse II - ST. PatrickHospital
Company: Christus Health
Location: Lake Charles
Posted on: April 26, 2024
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Job Description:
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. Responsibilities: Analyzes clinical
status of patient, current treatment plan and past medical history
and identifies potential gaps in physician documentation
Communicates with attending physician either verbally or through
written methodology to validate observations and suggest additional
and/or more specific documentation Maintains positive open
communication with physicians, nursing and all other disciplines
involved in the care of the patient Works closely with HIM Coding
staff to assure documentation of discharge diagnosis and any
co-existing co-morbidities are a complete reflection of the
patient's clinical status and care Maintains an electronic DRG
worksheet to assist coders on identifying all documented diagnosis
and procedures Updates DRG worksheet to reflect any changes
inpatient status/procedure/treatment and confers with the physician
to finalize diagnosis Consistently meets established productivity
targets for record review Designs and implements in collaboration
with physician leadership specific tools to support medical record
physician documentation Develops and implements 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
Assists in collection and organization of data for analysis by
appropriate medical and hospital committees Identifies strategies
for sustained work process changes that facilitate complete,
accurate clinical documentation Demonstrates competence to perform
assigned responsibilities is a manner that meets the
population-specific and developmental needs of the members served
by the department Appropriately adapts 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 Performs 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 Performs other
duties as assigned Requirements: Associate's Degree in Nursing RN
License in state of employment or compact Work Type: Full Time EEO
is the law - click below for more information: -
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf
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Keywords: Christus Health, Lake Charles , Clinical Documentation Registered Nurse II - ST. PatrickHospital, Healthcare , Lake Charles, Louisiana
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