Any Clinical Documentation Specialist here?

Trauma Columnist · Oct 28, 2007

I have never heard of a "clinical documentation specialist" - what do they do? What is their education? Thanks - curious.

kgard7777 · Oct 28, 2007

It involves either a nurse or HIM professional and they assist the coders with documentation from the doctors and nursing staff. They tend to work on the units and serve as the liason for the coding dept.

dbqp · Nov 1, 2007

I have never heard of a "clinical documentation specialist" - what do they do? What is their education? Thanks - curious.

CDS can be HIM coders and or RNs' nurses with good clinical knowledge.

Requires additional education of the MSDRG system and basic ICD coding.

example

One the function is to do real time concurrent coding .In identifying principle dx secondary dx, identifying complications and

commobidities and querying medical staff for accurate clear documentation in the patients medical record. The more specific and descriptive the documentation of patients diagnosis and condition provides better quality care for the patient, better data collection, anad for the coders provides timely and accurate coding of the medical record which also provides appropriate reimbursemnet.

kmcdsrn · Nov 8, 2007

I have never heard of a "clinical documentation specialist" - what do they do? What is their education? Thanks - curious.

I started as a CDS 6 months ago. With our organization a CDS reviews the charts to provide electronic data collection of primary diagnosis, secondary diagnosis, comorbidities, and major comorbidities. We query the doctors for specific documentation in order to best capture the severity of illness and clinical profile of the patient. We work closely with our coders to determine the most accurate DRG for Medicare billing. We use CDR2 software for documentation. I have my BSN, but we don't require a BSN. We have an RN team of reviewers on the frontline and we have a Coder Team for final review at time of discharge. I love my job. It is highly analytical and requires excellent critical thinking skills. My computer skills have greatly improved too.

kgard7777 · Nov 8, 2007

Thanks for your reply.. my question is how are the doctors? I hear they can be very mean and hard to get along with when doing CDI..

kmcdsrn · Nov 8, 2007

Just wondering how do you like or dislike your job.. pro's con's of dealing with the doctors etc.

I love my job as a Clinical Documentation Specialist. I am an RN CDS. I consider it a privilege to have a CDS position. Developing communication lines with the physicians has been challenging, but most of the doctors understand we are simply doing our job and they respond to our queries within 24 hours. We do have a rare physician who refuses to answer a query. We refer those situations to our Physician Advisors and the Advisors talk to the doctors at a peer to peer level. Overall, our physicians are supportive. The biggest challenge as a CDS is learning to read all of the doctors handwriting. We are changing to an Electronic Medical Record and hopefully this will be less of an issue.

philosophical · Nov 8, 2007

CDS can be HIM coders and or RNs' nurses with good clinical knowledge.
Requires additional education of the MSDRG system and basic ICD coding.
example
One the function is to do real time concurrent coding .In identifying principle dx secondary dx, identifying complications and
commobidities and querying medical staff for accurate clear documentation in the patients medical record. The more specific and descriptive the documentation of patients diagnosis and condition provides better quality care for the patient, better data collection, anad for the coders provides timely and accurate coding of the medical record which also provides appropriate reimbursemnet.

Is a HIM a Bachelor's level position in Health Information Mngt?

kgard7777 · Nov 8, 2007

Yes it is and then once you complete the HIM program you sit for the Registered health information admin. national exam to become registered and this will enable to work in all aspects of HIM.

The HIT is the associates degee program..

kmcdsrn · Nov 10, 2007

Thanks for your reply.. my question is how are the doctors? I hear they can be very mean and hard to get along with when doing CDI..

The doctors are more defensive than mean, no one likes to be told what to do and some physicians take the query process as a personal affront to them. We are fortunate in our organize, if a doctor is inappropriate to us we refer them to our Physician Advisor and the doctor is spoken to by his peer. We do not have to tolerate attacking or mean behavior by a physician. The physicians are less defensive as we improve our query process. On our learning curve, at times we have queried needlessly. The doctors love to educate and when we ask for clarification they are happy to provide it. As we grow in our knowledge base, the physicians are becoming more cooperative and helpful. We do not automatically report inappropriate query response/physician interaction to the Physician Advisor. Our process is to contact the coding manager and have a second chart review to determine if our query was justified. If the query is justified, we contact the Physician Advisor for assistance. More often than not, we find it is our mistake. Our software can also track the physicians that do not respond to queries and the PA is proactive in counseling them.

lbirk8353 · Apr 7, 2008

CDI Leaders,

I am working with a health system seeking to recruit a leader in clinical documentation improvement, who can design, implement and lead their program.

Any recommendations about who has been successful in building or leading a CDI program ?

kgard7777 · Apr 7, 2008

Yes, Orlando regional hospital here in Orlando Florida has an excellent program. pm me and i give can give u contact info