A Clinical Documentation Specialist is the person that makes sure all the records are accurate and updates the documentation as needed to maintain the required level of accuracy in the medical records. A CDS resolves documentation issues as they arise, and must have a solid working knowledge of multiple forms of medical coding, and is the professional that follow-ups with physicians and informs medical staff members of updated documentation methods. A CDSS has a wide base of knowledge, as indicated by the CDS certification website www.hcpro.com; “Clinical documentation specialists possess knowledge of a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology; knowledge of official …show more content…
medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; an ability to analyze and interpret medical record documentation and formulate appropriate physician queries; and an ability to benchmark and analyze clinical documentation program performance.” A CDS must have a strong knowledge of Microsoft applications, as this is the standard format for Electronic Health Records. Many employers request that the applicant be an RN to qualify for the position of CDS. Some of the tasks a CDS are responsible for, as indicated by an article titled How to Become a Clinical Documentation Specialist on www.study.com: “Clinical Documentation Specialist manages clinical trial and service documents.
They ensure accuracy and quality among medical coders, doctors, nurses, and other healthcare staff. They maintain charts, medical records, and reports and solve any issues involving documentation. Clinical documentation specialists like other types of medical records and health information technicians, work full-time. Such specialists work primarily during regular business hours, with some exceptions possible. The majority work in hospitals, clinics, or laboratories where medical clinical trials are taking …show more content…
place.” Clinical Documentation Specialist is not an entry level position in the Health Information Technology field; one must have upwards of 2-5 years of work experience in either nursing (LPN or RN) or health information management, or both fields in some instances. This means the candidate is already highly educated in order to acquire either licensing or certification. There are four ways that one can become a CDS, and all of them require time spent in the field doing the job to gain enough experience to qualify for the position of Clinical Document Specialist.
For an RN to become a CDS, one must have spent time as a staff nurse at either community health settings or hospitals, obtaining medical histories, assessing patients, and running tests. (Bureau)
A Registered Health Information Technologist (RHIT) has an Associate’s Degree and has become certified through the American Health Information Management Association (AHIMA). To acquire the necessary experience to become a CDS, should work as medical coder or record technician in hospitals, doctors' offices, clinics or other healthcare settings. RHITs are the keepers of the records, maintaining patient record security, coding their medical information, and keeping the database organized.
Registered Health Information Administrators (RHIA) hold a Bachelor’s Degree and are also certified. RHIAs work in any number of different healthcare settings as well, overseeing all patient records, and tracking and implementing all updated documentation methods.
The final method also takes several years; one can earn a certification through the Association of Clinical Documentation Improvement Specialists. To qualify for the CCDS exam, applicants need 1-2 years of professional documentation experience combined with college level
coursework. All of the above methods are ways to become a Clinical Documentation Specialist; each has its own challenges. I could not find any other levels of career development, but I did find that the CCDS certification was very new, developed in 2012, (CCDS) as a proving ground of one’s knowledge and ability. Along with the challenges there are some rewards. The 10 year growth rate of CDS is quite high, 16.6% according to the Bureau of Labor and Statistics, a CDS can earn a median pay of $65,900 to a top pay of $87,000, and was rated #52 by CNN’s Best Jobs in America. In conclusion, in order for me to become a CDS, I have to complete my RHIT or RHIA, and spend several years handling patient’s records and gain the practical and clinical experience necessary to prove that I am qualified enough to either become a CDS or to take the CCDS certification test through the Association of Clinical Documentation Improvement Specialists. At this moment, I have none of the skills or certifications that would allow me to become a CDS, but that doesn’t mean that I cannot change things.
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
According to www.reference.com, The Primary Job Duties include: taking the patient's history, performing physical exams, ordering laboratory tests and procedures, diagnosing, treating and managing disease, prescribing medications, coordinating referrals, performing certain procedures and minor surgeries, and lastly providing patient education and counseling to support healthy lifestyle of behaviors.
An associate degree is required to pursue a career as a Health Information Technician. As part of your educational training, some of the classes that will be needed include human anatomy and physiology, medical classification systems, medical terminology, concepts of disease and legal aspects of are required as the job moves toward using computers as its major form of storing information. Two other important training aspects that are required are, experience in supervising other personnel and experience in a health care clinic. This training program is usually offered in community colleges for the length of two years. The two year program is accredi...
Health Information Technology for Economic and Clinical Health Act consists of several subtitles. The subtitle D of the Health Information Technology for Economic and Clinical Health Act deals with the privacy and security issues that are associated with the electronic transmission of health information. The Health Information Technology for Economic and Clinical Health Act requires that as of 2011 all healthcare providers are going to be presented with the opportunity of financial incentives for showing meaningful use of electronic health records (EHRs). The proposed incentives will be offered up until 2015 and after that, penalties may occur for the failure of representing the use of EHR. The Health Information Technology for Economic and Clinical Health Act even started grants for the training centers for all staff members that are required to support a health information technology infrastructure. (www.healthcareitnews.com).
In a hospital patients are cared for around the clock, twenty-four hours a day and seven days a week. Hospital RN schedules are set up on rotation shifts meaning you might have to work night or days, holidays, and/or weekends (“Job…”). In a doctor’s office, school, or health center regular business hours are normally maintained (“Job…”). If an RN works for a home health care agency then their routine patient visits are mostly scheduled during business hours. However, if a nurse is on call they may be paged and required to make a visit on any day, at any time.
To become a CRNA, you must first receive a bachelor’s degree in nursing and attain the licensure of a registered nurse. You must also have at least one year of critical care experience, which is obtained in areas such as the emergency room or intensive care units. Once you have received licensure and critical care experience, you have to be accepted into an accredited anesthesia program with a typical duration of two years or longer. Once you successfully complete the program, you then take the national certification examination. To become specialized in specific patient populations, such as pediatrics or trauma, you would need to work at a specialty hospital. As of right now, there are no scholarly programs to become certified in subspecialties. There has been recent discussion focused on changing the crit...
The general requirements include a high school diploma, associates or bachelor's degree in nursing, a passing score on the NCLEX-RN exam, a state licensure as an RN, and work experience in a pediatric setting. After you meet the requirements, certification is usually the next step, although it may not be required by the state, but in some cases may be required or recommended by your employer. In Texas certification is required, and many require a bachelor’s degree.
... understand where and how each statistic is coming from. Health records are the primary source of data used in compiling health care statistics. The health record staff, therefore, may be responsible for .When a person gains this knowledge this allows for an Administrator are fully be able to make the proper changes in the healthcare organization that will end with the best effective and successful solution.
Inpatient service consultants are outside people who provide adept advices on coding and documentations to help organizations cling to their compliance standards. They will give consultation guidance to help organizations receives the maximum reimbursements. They also review and evaluate the accuracy of documentation and coding processes to assist organizations in reducing risks of malpractices. They identify potential diagnosis-related group (DRG) and coding errors and recommend appropriate timely changes to HIM professionals, coders in particular. Furthermore, they review the pre-bill cases that need attention to ensure good results. They are reference coding resources for the coders and other departments to ask for advices. Therefore, they
What is a medical coder? How do you become one and will it a great financial investment for your future? A medical coder is somewhat like a private investigator, you have
Registered nurses can work in many different settings and can perform many different procedures. They are required to perform many different jobs for their patients, Registered nurses are required to, “administer medication, consult with other healthcare providers, monitor patients, educate individuals and family and be responsible for managing medical records. They must also stay up-to-date with new tools and technology to help provide the best care to patients and families,” (Heinrich). If I want to become a registered nurse these are some procedures I will need to learn and know to how to do because these are things registered nurses do everyday. In addition to
Since my passion has always been assisting others and trying to improve their quality of life, with HIHIM degree I will have the opportunity to contribute in assisting healthcare organizations, their staffs, and patients. Not only will I gain the skills to maintain and manage healthcare data, but I will also gain vital skills to work with clinicians to ensure that the quality of patient care is correctly documented and to make sure their information is safe and secure from unauthorized use or
A person needs to be able to document numerous amounts of information in a neat and organized manner in the most accurate way possible. A nurse in the field needs to be able to organize medical records and provide the information needed to help improve the quality of health care to the patients. For providing the health care personnel with accurate information is important to delivering quality care to the patients and improve job performance of other nurses, doctors and other medical staff and
Introduction & Summary Clinical Decision Support systems are systems that aid in the provision of person-specific information and knowledge to patients, medical practitioners, clinicians and other persons within a health care setting. This person-specific information is presented and filtered according to the requirements in order to assist in enhancing the health care services and the general health of the patient. CDS system is comprised of a variety of tools including computerized reminders and alerts to healthcare practitioners and patients; focused summaries and reports of patient data; diagnostic support; order sets that are condition-specific; reference information with contextual relevance and documentation templates (Health IT 2013).
Initially, computers are the primary tool in any health care field. According to Diversified Health Occupations, “Computers can be used for Hospital information systems (HIS) or Medical information systems (MIS): managing budgets, equipment inventories, patient information, laboratory reports, operating room and personnel scheduling, and general records (p.315).” It does not matter which allied health professional a person wants to be; he or she must have, “the basic understanding of how a computer works and a basic understanding of the applications used in your field or profession (p.315).” On the other hand, Physical Therapists use a computer to bill or inform the insurance companies about any policies or procedures that the patient was involved in. Also, they use computers to schedule appointments and save the information pertaining to the patient relative to their visit. Computers will always play a major role in the workplace.