Clinical Documentation Specialist

Clinical Documentation Specialist

The Clinical Documentation Integrity Specialist (CDIS) provides clinically based, concurrent and retrospective reviews of all inpatient medical records. CDI Specialists strive to ensure accurate, complete, compliant, concise and consistent documentation that reflects the true clinical scenario of the patient’s encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and Intensity of Services (IOS) rendered to provide quality care and treatment to the patient. The Clinical Documentation Integrity Specialist serves as a liaison between leadership, medical staff, nursing, coding, case management and quality departments.