Clinical Documentation Job Description
Clinical documentation
provides quality review of clinical study documentation to ensure study compliance with department operating procedures, GCP and applicable regulatory requirements;.
Clinical Documentation Duties & Responsibilities
To write an effective clinical documentation job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical documentation job description templates that you can modify and use.
Sample responsibilities for this position include:
Applies federal and state documentation and coding (ICD 10) guidelines to ensure physician and hospital compliance
Perform reviews of inpatient records to (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate and optimal DRG assignment
Provide the expertise and guidance to enhance concurrent clinical documentation practices
Work to ensure the quality and accuracy of clinical documentation is reflected for the care provided
Be responsible for driving processes and achieving results while working effectively with diverse groups to build collegial relationships
Participate in task forces
Conduct extensive reviews of medical records
Assure the best reflection of diagnosis, clinical status, treatments and discharge
Recognize opportunities for clarification/improvement
Communicate with physicians and members of the staff
Clinical Documentation Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Clinical Documentation
List any licenses or certifications required by the position: CCDS, RHIA, RHIT, CDIP, CPC, OASIS, BLS, CDS, CCS, CCM
Education for Clinical Documentation
Typically a job would require a certain level of education.
Employers hiring for the clinical documentation job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Health Information Management, Medical, Associates, Science, Health, Healthcare, Graduate, Computer
Skills for Clinical Documentation
Desired skills for clinical documentation include:
Clinical documentation requirements
Medical terminology
Pathophysiology
Regulatory environment
Federal
Referral policies and procedures
Pharmacology
Procedures
Clinical documentation requirements that identify clinical conditions
ICD-9-CM
Desired experience for clinical documentation includes:
Handle CDS reporting
Review and recommend opportunities for documentation improvement
Interact with physicians and other healthcare professionals
Educate members of staff
Code administrative and regulatory documents
Verify documentation
Clinical Documentation Examples
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Clinical Documentation Job Description
Job Description Example
Our innovative and growing company is hiring for a clinical documentation. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical documentation
- Filing the essential clinical documents and maintenance of the TMF
- Performs quality control review of electronic documents uploaded in the eTMF
- Performs quality control review of paper essential documents to the TMF
- Tracks receipt of essential documents from clinical study teams submitted to TMF
- Use key performance indicators to monitor performance of adoption and implementation of the eTMF process
- Compiles data, performs analysis and advises the documentation team on interpretation and/or validation of data
- Ensure that the Pharma TMF Reference Model and the associated zone content is aligned with current and future thinking, internally and externally
- Drive continuous improvement of specific processes/projects/systems/programs/policies
- Improve the overall quality and completeness of clinical documentation
- Facilitate modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medi-cal, Managed Care)
Qualifications for clinical documentation
- Current California RN Licensure or Current Coding Certification by AHIMA is required
- Required to maintain continuing education hours in coding or nursing as required to keep current certifications in nursing and/or coding
- Current certification in Clinical Documentation (CCDS or CDIP) strongly preferred
- Strong interpersonal, communication (verbal, non-verbal, and listening skills)
- Understand Adult Learning Theory
- Competent computer skills including word processing, spreadsheets, and presentation software
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Clinical Documentation Job Description
Job Description Example
Our growing company is looking for a clinical documentation. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical documentation
- Analyze reports and identifies trends and statistical significance in coding opportunities CDI opportunities that will assist in the organizational process of documentation improvement
- Maintain confidentiality of information acquired pertaining to patients, physicians, associates, and visitors to the Hospital
- Assist with developing educational and training materials on clinical documentation improvement for CDIS training routine education of medical staff, residents, physician extenders, nursing, ancillary personnel, case managers and others
- Active study team member for assigned studies
- Updates and oversees CTMS data entry in a contemporaneous manner for assigned TA
- Leads team of application analysts building and supporting Epic’s clinical documentation including Inpatient – all clinicians, Stork Obstetrics, ASAP ED and Home Health applications
- Initiates and facilitates change management through established communication methods
- Develops and assists with communications to the organization and customers regarding the various Epic technology initiatives
- Determines and negotiates for required resources to accomplish goals and objectives
- Routinely monitors, discusses, and reviews work performance and career plans of direct reports
Qualifications for clinical documentation
- Fundamental knowledge of the clinical drug development process and clinical trial methodology, ICH/GCP and regulatory guidelines/directives
- Associates degree or B.S
- CA RN licensure OR Doctor of Medicine (MD) or Doctor of Osteopathy (DO) OR foreign trained physician required
- RN, LPN with 2 years acute care nursing experience (e.g., medical/surgical, ICU, Case Management, ), current licensure to practice professional nursing in the Commonwealth Of Kentucky or eligible, required
- RHIA, RHIT, CCS, CCA certification a plus
- Must be able to work with physicians and staff in a collaborative manner
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Clinical Documentation Job Description
Job Description Example
Our company is growing rapidly and is hiring for a clinical documentation. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for clinical documentation
- Demonstrates holistic understanding and awareness of direct reports
- Fosters and maintains positive relationships with customers, and team members, providing guidance, focus and support in decisions as they relate to their technology needs
- Guides appropriate resources in the planning, design and deployment of technology solutions for the various business efforts, facilitating the group to consensus
- Creates an increasing awareness of similar/parallel applications, which may be of benefit to the service line, region, site or business unit, ultimately spreading “best practices” across the enterprise
- Ensures that all support efforts are accomplished within budget, on time, according to specifications, and meets business objectives
- Provides thorough and comprehensive reporting analysis
- Assists with department budget development and management
- Act as single point of contact or escalation for customers and facilitating contact with the correct resources
- Advises teams on the current Information Systems activities as it relates to their area of responsibility or location
- Gains an understanding of strategic business goals and associated timelines
Qualifications for clinical documentation
- Must possess a comprehensive knowledge of acute care nursing experience, as normally obtained through a Bachelor of Science, Nursing (BSN) and at least five years of current acute hospital care experience
- Inpatient coding experience desired
- Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills
- Demonstrated ability to use a standard desktop and windows based computer system, including a basic understanding of email, internet, and computer navigation
- Ability to use other software as required to perform the essential functions on the job
- Experience with Microsoft Office Word, Excel and PowerPoint software preferred
4
Clinical Documentation Job Description
Job Description Example
Our innovative and growing company is hiring for a clinical documentation. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical documentation
- Leads and directs work assignments of internal and external resources to ensure support efforts are accomplished successfully
- Manages multiple priorities to effectively integrate the use of Epic technology in achieving AHS strategic objectives
- Represents Information Services & Support as a contributing and active member of various committees
- Demonstrates and exercises effective issue escalation
- Reviews and oversees documentation standardization and improvement efforts
- Demonstrates strong verbal/written communication skills, remains poised when dealing with conflict and volatile situations
- Serve as the steward of the study eTMF to make sure the process to ensure completeness, quality and timeliness is followed by the study team
- Work with product and study teams to prepare for inspection readiness and during inspections and audits as necessary
- Effectively communicate and drive document management compliance and quality issues to the clinical study teams and management
- Present eTMF at study Kick-off meeting and investigator meetings (CRA training) and attend regular study team meetings as applicable to report on the status of the TMF
Qualifications for clinical documentation
- Able to work with interruptions and perform detailed tasks
- Proficient on working on different projects simultaneously and coordinate work to meet deadlines
- Skilled ability to concentrate and read for long periods of time
- Strong critical thinking skills and ability to integrate knowledge
- Comfortable operating independently in a collaborative, shared leadership environment
- Ability to educate all members of the healthcare team related to clinical documentation
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Clinical Documentation Job Description
Job Description Example
Our innovative and growing company is looking for a clinical documentation. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical documentation
- Support the clinical study teams to ensure study TMFs are submission and inspection ready at all times
- Prepare the study specific TMF plan and corresponding study inventory list and insure they are current throughout the study and finalized at study completion
- Conduct documentation reviews of the TMF looking for areas missing significant documentation, logical checks (missing versions, missing documentation from 1572 participants, correct number of sites, etc), gross errors in location, inconsistencies in naming conventions
- Ensure QC reviews are conducted as prescribed in the TMF plan and that issues identified are addressed
- Manage deletion/demotion requests throughout the duration of the study (Once Veeva eTMF workflow is in place)
- Answer any filing queries or general Veeva eTMF questions from CRO/study team
- Ensure Veeva eTMF is set up for the study and that countries and sites are added as needed
- Direct management of Clinical Documentation Specialists within the corporate CDI team
- Provide staff with Continuing education and training
- Collaborate with the Corporate Director of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the CDI dept
Qualifications for clinical documentation
- Ability to interact with stakeholders throughout the organization (business owners, HIM professionals, Informatics professionals, ) is required
- Graduate of associate’s in nursing program or health information technology program or other related Bachelor's degree
- Proven ability to clearly convey information orally and in writing (technical documentation, presentations to business stakeholders, ) to audiences with varied and sometimes limited technical knowledge
- Ability to achieve work through others who do not report directly to them with guidance
- In depth knowledge of Trial Master File Reference Model (a supported initiative through the Document and Records Management SIAC of the Drug Information Association (DIA))
- Broad knowledge of clinical documentation management