Clinical documentation is the foundation of each patient encounter. In order to be significant, the documentation of the health care practitioner must be clear, concise, consistent, complete, precise, reliable, timely, and legible to accurately depict the patient’s severity of illness and resources provided.

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The collaboration between physicians, other healthcare professionals, clinical documentation integrity specialist, and coders is vital to support high-quality patient care which reflects the severity of illness and risk of mortality.

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One of the important task of the clinical documentation is reviewing and analyzing each patient’s chart for documents to properly record relevant diagnoses and procedures for patients, in compliant with federal and state regulations, and clarifying or querying when physician documentation is conflicting, vague or missing.

 

With ever growing changes in federal and state policies and regulations, Certified clinical documentation specialists by ACDIS and Certified clinical documentation practitioner by AHIMA

are in high demand today and is now an ever-growing need for such skills and specialty.

 

RN Link will provide you the basic training on how to become as successful clinical documentation specialist/practitioner. We are approved by the California Board of Registered Nursing, Provider Number CEP16899, for CEUS. Our CEUs are also accepted by AHIMA and ACDIS. We offer both webinars and online continuing education. 

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Call us for more information at 800-853-2810