Accountable for improving the overall quality and completeness of physician and NP/PA clinical documentation of diagnoses and procedures used in inpatient admissions. Facilitates clinical documentation improvement through extensive daily interaction with physicians, midlevel providers, healthcare team and coding staff to achieve timely, accurate, and complete documentation. Provides for a complete medical record at patient discharge which accurately captures the patient's acuity and severity levels. Ensures documentation that results in accurate clinical data to measure and report outcomes which support appropriate reimbursement for the level of services rendered to the patient. Educates all members of the patient care team on clinical documentation improvement.

Concurrently reviews inpatient medical records to identify documentation opportunities:

a. Reviews all clinical documentation to assure all pertinent conditions are documented to reflect severity of illness and acuity of care;

b. Establishes the working DRG assignments. When necessary, collaborates with coding liaison to determine accurate working DRG.

c. Identifies and queries physicians, nurse practitioners, and physicians' assistants of potential clarifications related to the principal diagnoses, comorbid conditions and complications, and/or procedures based upon industry standards, hospital policy, and clinical indicators; assures physician documents their responses within the record in a compliant manner;

d. Ensures timely data entry and closure of cases in electronic database.

e. Conducts follow-up reviews to ensure points of clarification have been recorded in the patient's medical record.

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