The Clinical Documentation Specialist will provide active, concurrent and retrospective review of provider documentation, query for clarification, provide feedback, and educate clinical care providers to improve the documentation of all conditions, treatments and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, the CDS will work with the physicians to ensure high quality documentation that supports accurate representation of the care provided to the patient as reflected through MS-DRG assignment, case mix index, severity of illness, risk of mortality, quality measures, physician profiling, hospital profiling and reimbursement rules.
The CDS exhibits a comprehensive knowledge of clinical documentation requirements, DRG assignment, clinical conditions or procedures, and understanding of coding concepts and guidelines. The CDS is also responsible for communicating and educating members of the patients care team regarding documentation guidelines; and collaborating with other stakeholders throughout OHSU, including Quality; Enterprise Coding; and
As the state's only health and research university, OHSU brings together patient care, research, education of the next generation of health care providers and scientists and community service to improve the health and well-being of all Oregonians.The university is a conduit for learning for more than 2,800 students, providing training to interns, residents and fellows in postgraduate medical and research. It is the only place in Oregon that grants doctoral degrees in medicine, dentistry and nursing. OHSU cares for more than 251,000 patients each year from around the region and takes a leadership role in contributing to solutions involving the health of the state and the nation, such as health care access and transparency, ethics and workforce shortage. Beyond providing critical health care services, quality education and cutting-edge research, OHSU also is a key economic and social force in the Northwest. With an annual operating budget of $2.06 billion and more than 14,000 employees, OHSU is Portland?s largest employer. Its size contributes to its ability to provide... many services and community support activities not found anywhere else in Oregon. For more information visit http://www.ohsu.edu/xd/about/index.cfm