So...any Clinical Documentation Specialists?

Nurses General Nursing

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Specializes in CDI Supervisor; Formerly NICU.

Any of you do this job? What can you tell me about your day? Gonna accept a position tomorrow. CNN Money has it listed at #52 on their list of Best Jobs in America. I hope they're right.

Thanks!

Specializes in LTC, med/surg, hospice.

I'm not one but congrats on the position. Is this position where part of the duties including audit of the chart to ensure the physician documentation matches the treatment plan and diagnosis or some form of utilization management?

Specializes in CDI Supervisor; Formerly NICU.

From the internet: These professionals review records for coding accuracy, follow-up with physicians and inform medical staff members of updated documentation methods.

Basically, you ensure that doc/nurse charting represents the true clinical picture of the patient, in order to receive the most accurate (and $$$) reimbursement from Medicare and etc. For instance, if the pt has CHF, but also has other comorbidities, you'd make sure the MD documented the comorbs and not just "Pt has CHF", in order to represent a truer picture of pts health and need for services.

@Bortaz, RN

I saw on you page that you have a NICU background, as a fellow NICU nurse also wanting to become a clinical documentation specialist, I was wondering did you find it difficult to get a CDS positions with this background? I'm wondering because most of the positions I've seen posted require at least 5 years of acute care experience. I've been considering taking a CDS boot camp to increase my chances since all of my nursing experience only insolves pediatrics and neonates, but would rather save my $1300 if I can land a job without it.

Specializes in CDI Supervisor; Formerly NICU.

My situation is likely different than yours because I live on the border with Mexico and conventional wisdom doesn't apply down here. I got the first cdi job I applied for with just nicu experience. My understanding is that the position is harder to get in normal areas of the country.

It has been challenging for me because I've had to basically relearn all the adult stuff I haven't used since nursing school.

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