JefferyKieth

I too never really consider the impact of my documentation on the facility, I was wrapped up in patient care. But my eyes were opened when I started my data abstraction and analysis position. Your work not only impacts patient care, but nursing work, as well as hospital reimbursement. Data is reported not only to CMS but also TJC and many non-governmental agencies like leapfrog, hospital compare, hospital associations, state organizations, etc.

My current position is in Performance improvement abstractor and analyst. There are currently 6 abstractors in our department and we are hiring 2 more. It definitely is a lot of computer work. I had never had experience with this aspect of Nursing field, having been in ED, Critical Care, Radiology and Vascular access. Upon completing my Masters of Science in Health Administration I knew I wanted to expand my experience. As an Abstractor/Analyst at my facility we are responsible for reviewing the medical record to verify if the documentation supports inpatient and outpatient core measure requirements that are reported to TJC, and CMS. In addition to this abstraction we support service lines in obtaining certification like Comprehensive Stroke Center certification, IBD care, Pediatric Cardiology etc. I also review records that have been flagged as having triggered a Patient Safety Indicator, reviewing documentation to verify this and or documentation that supports its overturning. We work closely with other healthcare team members, recommending changes in processes and/or documentation to quality care. I also review every mortality in the organization and send it on to physicians for further review. I have the opportunity to work from home a couple of days a week and the stress is much less. I am over that my adrenaline levels no longer wants to respond to emergent situations. It gives me the opportunity to use my skills that I have honed over the last 30 years to improve the care of more than one patient at a time. It is very much like detective work in electronic form. You will become very familiar with coding and it will open other doors as well.