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CDI Functions
#2
by
anniebabe1
- opened
😃: What do clinical documentation specialists do?
🤖: Clinical documentation specialists (CDS) are healthcare professionals who are trained to ensure that patient information is accurately, completely, and concisely documented in electronic health records (EHRs). Their primary role is to improve the quality and completeness of clinical documentation, which in turn improves patient care and contributes to better healthcare outcomes.
Here's a breakdown of the key responsibilities and functions of a clinical documentation specialist:
Core Functions:
- Review and Analyze Clinical Documentation: CDSs meticulously review patient charts to identify gaps in documentation, inconsistencies, and areas for improvement. They look for vital information that might be missing, such as diagnoses, procedures, medications, allergies, and relevant medical history.
- Provide Education and Training: CDSs educate healthcare ...