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Ernest Smith
Clinical Documentation Consultant
Summary
Accomplished and results-oriented Clinical Documentation Consultant with over 7 years of experience in improving documentation processes, enhancing healthcare quality, and optimizing reimbursement outcomes in the healthcare industry. Expertise in clinical documentation improvement (CDI) program development and implementation, clinical documentation template creation, and physician and nurse collaboration to ensure accurate and compliant documentation. Proven ability to analyze data, identify trends, and make recommendations that drive continuous improvement in clinical documentation practices.
Key achievements include a 20% improvement in CDI program documentation process, resulting in a 30-day reduction in average length of stay, and a 5% increase in case mix index (CMI) through the implementation of a comprehensive CDI program. Possesses a deep understanding of medical terminology, ICD-10-CM/PCS coding, DRG validation, and medical record review principles. Committed to delivering excellence in clinical documentation and ensuring optimal patient care.
Education
Bachelor of Science in Health Information Management
November 2014
Skills
- Medical Terminology
- ICD-10-CM/PCS Coding
- DRG Validation
- Medical Record Review
- Clinical Documentation Improvement
- Data Analysis
Work Experience
Clinical Documentation Consultant
- Educated and trained healthcare professionals on clinical documentation best practices and quality measures.
- Utilized clinical decision support (CDS) tools to assist clinicians in capturing accurate and complete patient information.
- Conducted chart reviews and provided feedback to clinicians on documentation deficiencies and improvement opportunities.
- Participated in clinical documentation design and implementation projects to improve patient care and streamline documentation processes.
Clinical Documentation Consultant
- Improved CDI program documentation process by 20%, resulting in a reduction of 30 days in average length of stay.
- Developed and implemented a clinical documentation improvement (CDI) program for a 300bed hospital, which resulted in a 5% increase in case mix index (CMI).
- Created and maintained clinical documentation templates and guidelines to ensure consistent and accurate documentation across the organization.
- Collaborated with physicians and nurses to improve clinical documentation practices and ensure compliance with regulatory requirements.
Accomplishments
- Developed and implemented a clinical documentation improvement program that resulted in a 15% increase in documentation accuracy and completeness
- Collaborated with physicians and nurses to streamline documentation processes, reducing documentation time by 20%
- Led a team of clinical documentation specialists in implementing a new electronic health record system, resulting in improved documentation quality and reduced errors
- Developed training materials and conducted workshops to educate healthcare professionals on best practices in clinical documentation
- Collaborated with quality improvement teams to identify and address areas of documentation deficiency, leading to improved patient outcomes
Awards
- Recognized as Top Clinical Documentation Consultant in the State by the Association of Clinical Documentation Improvement Specialists (ACDIS)
- Awarded the Clinical Documentation Excellence Award by the American Health Information Management Association (AHIMA)
- Received the Rising Star Award from the National Association of Clinical Documentation Specialists (NACDS)
- Recognized as a Certified Clinical Documentation Specialist (CCDS) by AHIMA
Certificates
- Certified Clinical Documentation Specialist (CCDS)
- Certified Physician Documentation Specialist (CPDS)
- Registered Health Information Technician (RHIT)
- Certified Health Data Analyst (CHDA)
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How To Write Resume For Clinical Documentation Consultant
Highlight your expertise in clinical documentation improvement (CDI) programs.
CDI programs are essential for ensuring accurate and complete documentation, which can lead to improved patient care, reduced costs, and increased revenue.Quantify your accomplishments.
When describing your experience, be sure to include specific numbers and metrics that demonstrate the impact of your work.Showcase your knowledge of medical terminology and coding.
Clinical documentation consultants need to be familiar with medical terminology and coding in order to properly review and analyze patient records.Demonstrate your communication and interpersonal skills.
Clinical documentation consultants need to be able to effectively communicate with physicians, nurses, and other healthcare professionals in order to improve documentation practices.
Essential Experience Highlights for a Strong Clinical Documentation Consultant Resume
- Develop and implement clinical documentation improvement (CDI) programs to enhance documentation accuracy and completeness.
- Collaborate with physicians and nurses to improve clinical documentation practices and ensure compliance with regulatory requirements.
- Create and maintain clinical documentation templates and guidelines to standardize documentation across the organization.
- Conduct chart reviews and provide feedback to clinicians on documentation deficiencies and improvement opportunities.
- Analyze data, identify trends, and make recommendations to drive continuous improvement in clinical documentation processes.
- Educate and train healthcare professionals on clinical documentation best practices and quality measures.
- Utilize clinical decision support (CDS) tools to assist clinicians in capturing accurate and complete patient information.
Frequently Asked Questions (FAQ’s) For Clinical Documentation Consultant
What is a Clinical Documentation Consultant?
A Clinical Documentation Consultant (CDC) is a healthcare professional who works with clinicians to improve the quality and accuracy of patient medical records. CDCs help to ensure that patient records are complete, accurate, and compliant with regulatory requirements. They also work to improve the efficiency of the documentation process and to reduce the risk of medical errors.
What are the benefits of using a Clinical Documentation Consultant?
There are many benefits to using a Clinical Documentation Consultant, including: * Improved quality and accuracy of patient medical records. * Increased efficiency of the documentation process. * Reduced risk of medical errors. * Improved compliance with regulatory requirements. * Increased revenue.
What are the qualifications for a Clinical Documentation Consultant?
Clinical Documentation Consultants typically have a bachelor’s degree in health information management or a related field. They also typically have experience working in a clinical setting, such as a hospital or clinic. Clinical Documentation Consultants must be familiar with medical terminology and coding, and they must have strong communication and interpersonal skills.
How much do Clinical Documentation Consultants make?
The salary for Clinical Documentation Consultants varies depending on their experience, location, and employer. According to the American Health Information Management Association (AHIMA), the median annual salary for Clinical Documentation Consultants is $75,000.
What is the job outlook for Clinical Documentation Consultants?
The job outlook for Clinical Documentation Consultants is expected to be good over the next few years. The demand for Clinical Documentation Consultants is expected to increase as healthcare providers focus on improving the quality and efficiency of their documentation processes.
What are the challenges of being a Clinical Documentation Consultant?
There are several challenges that Clinical Documentation Consultants may face, including: * The need to keep up with changes in medical terminology and coding. * The need to work with a variety of clinicians and other healthcare professionals. * The need to balance the need for accuracy and completeness with the need for efficiency.
What are the rewards of being a Clinical Documentation Consultant?
There are several rewards to being a Clinical Documentation Consultant, including: * The opportunity to make a difference in the quality of patient care. * The opportunity to work with a variety of clinicians and other healthcare professionals. * The opportunity to learn about new medical technologies and treatments.
What is the future of Clinical Documentation Consulting?
The future of Clinical Documentation Consulting is bright. As healthcare providers continue to focus on improving the quality and efficiency of their documentation processes, the demand for Clinical Documentation Consultants is expected to grow. Clinical Documentation Consultants will play an increasingly important role in ensuring that patient medical records are accurate, complete, and compliant with regulatory requirements.