Performs analysis of inpatient and outpatient records to assure their completeness. Assigns physician deficiencies in a timely manner. Monitors incomplete records, provides notification to physicians of delinquencies and performs physician suspension when required. Provides back up for HIM receptionist as needed assisting physician offices and patients with requests.
Analyzes all inpatient and outpatient records for completeness, assigns physician deficiencies in One Content. Maintains analysis completion at 1-2 days 95% of the time.
Performs physician notification of incomplete records on a daily and weekly basis by sending reminders to physicians including making phone calls when necessary. Notification is sent three times a week to ER Director for all ER physicians. Notices sent at 48 hours for operative reports and 72 hours for all other deficiencies once 14 days old.
Performs physician suspension for delinquent records, reinstates physician when records complete. Keeps track of monthly suspension days.
Works closely with physician and physician offices to help resolve any issues related to record completion. Also works closely with information services on issues related to problems physicians may have encountered.
Monitors pending documentation queue in One Content to make sure physicians are notified of documentation holding up coding and notifies coder when documentation is available.
Monitors and performs follow up on ICD 10 queue in One Content for missing diagnosis codes on orders; notifies coder when documentation is available.
Monitors reanalysis and decline queues in One Content to verify physician completion and investigate possible reassignment of deficiencies, if appropriate. Works with physician to resolve issues related to these deficiencies.
Preps, scans and indexes physician documentation into One Content. Provides back up to HIM receptionist for loose sheet scanning as needed.
Provides back up for HIM receptionist as needed assisting physician offices and patients with requests. Orders routine supplies for department.
Education: High School Diploma or equivalent.
Experience: At least one year previous experience in acute care hospital or clinic setting with responsibility for maintaining documentation completeness in an electronic medical record environment.
License or Certification: None required.
Required Skills or Knowledge: Possess knowledge of CIHQ, federal and state patient record completion requirements; thorough understanding of Medical Staff rules and regulations as related to chart completion. Good communication skills required to be able to explain physician deficiencies and assist physicians in their record completion.
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