So excited!!!

[Hotfornursing, RN]

Hello all, so excited, wanted to share and needing some input from my nursing community. I was just offered my dream job in as a clinical documentation specialist at my local hospital and will start at the end of this month. Needless to say, I am thrilled beyond belief, but a little nervous, as I am new to this field. So my question is, what type of training should I expect for this position, any tips or advice would be much appreciated.

[NurseEvolution]

I was a CDS in a prior position and really liked it. I had stepped away from the bedside, but felt that I was able to keep current on nursing practice by having my nose in charts all day, which I enjoyed.

My training was with a major vendor who developed one of the original DRG systems. This may be different for you (as it was a few years back), but you will learn coding basics and MS-DRG-related rules that will support the type of documentation you will be looking for and encouraging Clinicians to use.

You will gain a whole new knowledge set and different perspective on healthcare in this role. It should also be interesting with the transition to ICD-10.

Best wishes!

[rg42284]

Congrats on the new position and good luck.

I, too, was in your shoes a while back. My biggest advice is to make sure you understand what you are querying for and ensure the diagnosis will actually meet UHDDS guidelines and are clinically substantiated. Examples - A small drop in hemoglobin during surgery does not necessarily warrant a diagnosis of anemia due to acute blood loss. A postop patient who remains on the vent overnight or two nights may not meet the criteria for acute resp. failure following surgery.

[Caffeine_IV]

Congratulations! I will be working in a very similar role (the job title is slightly different).

The training here is in partner with JA Thomas.

I'm very excited and nervous as well.