Clinical Documentation Specialist
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As a clinical documentation specialist, I facilitate modifications to clinical documentation through extensive concurrent interactions with physicians and other clinicians to reflect appropriate clinical severity, complications and co-morbidity. Educating internal staff on clinical documentation, recent coding guidelines, reimbursement issues and relevant quality and performance improvement opportunities. Identify quality of care issues in documentation and seek resolution of issues through appropriate channels.
Review of medical records in hospitalized patients to identify the most appropriate principle Diagnosis, assign a working DRG, perform initial review, concurrent reviews and retrospective reviews to ensure the DRG accurately reflects the principle diagnosis and all comorbid conditions with the discharge summary. Development and support of strong professional relation with CDI specialists, coding staffs, physician advisors and medical providers across the health system. Taking part in CDI-Physician education, CDI-coding education, Jzanus education sessions to improve proper documentation.
Clinical Documentation Specialist - Yale New Haven Hospital - CT
(2017-02)
As a clinical documentation specialist, I facilitate modifications to clinical documentation through extensive concurrent interactions with physicians and other clinicians to reflect appropriate clinical severity, complications and co-morbidity. Educating internal staff on clinical documentation, recent coding guidelines, reimbursement issues and relevant quality and performance improvement opportunities. Identify quality of care issues in documentation and seek resolution of issues through appropriate channels.
Review of medical records in hospitalized patients to identify the most appropriate principle Diagnosis, assign a working DRG, perform initial review, concurrent reviews and retrospective reviews to ensure the DRG accurately reflects the principle diagnosis and all comorbid conditions with the discharge summary. Development and support of strong professional relation with CDI specialists, coding staffs, physician advisors and medical providers across the health system. Taking part in CDI-Physician education, CDI-coding education, Jzanus education sessions to improve proper documentation.
Remote CDI Specialist - Waterbury Hospital, CT / Prospect Medical Group - CT
(2017-11 - 2019-05)
I was hired as a weekend CDI Specialist to maintain a constant high review rate and to resolve weekend coder-CDI mismatches. It was a new challenge for me as Waterbury Hospital was building their CDI department. With dedication, hard work and team-playing with existing CDI coworkers CDI department was able to reach their monthly goal for past few months.
I brought some new Ideas to the organization. We started monthly CDI educational review sessions, where I took the leading roll to conduct first presenter in three new topics (following new coding guide lines). I learned a new EMR system there (Cerner) while I have been working in Yale New Haven Health in EPIC system.
Clinical Reviewer / Chart Reviewer - Lincoln Hospital - NY
(2015-08 - 2016-04)
As a chart reviewer in Emergency Department (ED) since August 2015. Working in ED I mainly reviewed physicians assessment and disposition notes, RN triage notes, reassessment notes. Making sure patient safety and safe medical practice have been implemented.
Hand hygiene, patient isolation measures and critical lab values are notified in time to assigned providers and necessary steps have been taken. Patients at risk for suicide get Columbia risk screening, risk assessment and whether appropriate measures have been implemented to prevent suicide. Making sure discharge instructions and advice to patients are appropriate.
For inpatient chart review I make sure general consent form is signed, dated and timed properly, informed consent form is completed properly if there is any procedures or transfusion is done, restrained form completed appropriately, renewal of restrain order given if necessary, urinary catheter is removed after 24h, discharged instructions are given and follow-up appointments are scheduled. I also had to attend performance improvement (P.I) meetings, present quarterly performance of physicians, RNs and medical staffs for emergency department. Discuss different plans
Medical Residency - Rajshahi Medical College Hospital - Bangladesh
(2002-10 - 2003-10)
As an intern I worked under direct supervision of the attending physicians of each department. My duties ranged from admitting the patients, taking their history and doing physical exams, ordering lab works and following up with them to taking active part in the decision making process for their treatment, making discharge plans and counseling the patients (and their families when required). I had to present cases during the morning report & morning rounds to the attending physicians and make amendments to the treatment plan as instructed by the attending physicians.
I had to do night floats, supervised by senior residents. I assisted in surgeries while rotating in Surgery (and allied specialties) and OB-GYN; I also performed procedures such as thoracentesis, lumber Puncture etc as well as routine IV access, urinary catheterization, minor surgeries. Received an excellence letter after 6 months of rotation from Head of Medicine Department.
MD / ECFMG - Educational Commission for Foreign Medical Graduate Certificate - USA (2014-10)
M.B.B.S - Bachelor of Medicine and Surgery - Bangladesh (2002-05)
