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The Clinical Documentation Specialist (CDS) has a broad clinical knowledge base and understanding of DRG documentation requirements. The primary purpose of the CDS is to facilitate the improvement in the overall quality, completeness and compliance of clinical documentation in the medical record. The CDS facilitates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff and other caregivers utilizing coding and clinical documentation expertise. The CDS will manage a concurrent query process to accurately capture the appropriate documentation. The CDS is also responsible for educating all members of the patient care team on appropriate documentation to support the use of hospital resources and the acuity of patients served.
