GENERAL SUMMARY:

The Clinical Documentation Specialist (CDS) uses clinical, coding, and Clinical Documentation Integrity (CDI) knowledge and experience to improve the quality and integrity of documentation in the medical record. Identifies factors influencing the complexity of a patient’s diagnosis and treatment plan. Serves as a CDI resource and works collaboratively with physicians, advanced practice providers, nursing, and ancillary services. Champions for advancement of the Henry Ford Health CDI program.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

1. Review clinical documentation and diagnostic results in the electronic medical record (paper record during downtime) for patients within 48 hours of admission to ensure that signs, symptoms, diagnoses, and response to treatment are accurately documented and the medical record reflects the patient’s severity of illness, risk of mortality, and resource consumption.

2. Use clinical experience and ...