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clinical documentation tools

What is a Clinical Documentation Specialist?

A CDS- or Clinical Documentation Specialist is an expert who organizes patient information within a medical establishment. The job of a CDS involves complex tasks, and CDS experts typically work together to complete these tasks. The experts use all types of clinical documentation tools that help them record and organize an immense data load. The clinical documentation specialist must comply with HIPPA requirements and other important rules and regulations.

The expert also reviews medical records to ensure that all these codes have been introduced correctly. There is teamwork between CDS experts to achieve the best results, but of course, their work is aided by the different clinical documentation tools existent on the market. The clinical documentation specialist also needs to ensure that all the gathered medical information is recorded in the most detailed and accurate manner. Whenever the specialist considers that there are some gaps in the recorded data, he needs to communicate with other health departments and experts to ensure these records are indeed accurate and up to date for each patient.

What are some other job tasks of a CDS expert in general?

  • The evaluation of different patient records
  • Reviewing records to ensure proper documentation
  • Document query input into a unique system that allows other physicians and specialists to access it
  • Follow-up on all types of queries and answers
  • Ensuring the health establishment receives the correct Medicare reimbursement.
  • CDS experts can also contact the insurance company of a patient whenever necessary to find out more information and to get access to extra data

The work of a CDS involves a lot of in-depth research and desk work. Checking different values and records, inputting different codes, sorting paperwork, locating documents, and constant communication with other departments are significant tasks that make up a day’s work for a clinical documentation specialist. CDS professionals need in-depth academic knowledge of healthcare & computer information systems, pharmacology and pathophysiology, medical terminology, and data management systems.

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