Description
Summary:
Accurate management of patient data integrity in the Electronic Health Record (EHR) is foundational to the care of all the patients within CHRISTUS Health. The CHRISTUS Health patient database contains over 10 million patient records and serves as the foundation of care, patient communication, and clinical coordination within the CHRISTUS network and beyond.
Under general supervision, this Job is responsible for maintaining the integrity of the content of the CHRISTUS electronic health record by performing in-depth investigations of questionable data entry and correcting as appropriate. The Chart Correction Nurse provides issue identification, assessment, resolution, and technical support to achieve desired outcomes and compliance with CHRISTUS Health policies/procedures and standards.
This role analyzes chart correction scenarios and performs subsequent hands-on technical chart corrections as part of daily work responsibilities. This Job serves as an organizational resource for issues involving chart correction, identity, and Epic instructional support.
The Chart Correction Nurse works with the Chart Correction Analyst team at the center of the chart correction process, facilitating the correction of clinical information throughout all inpatient and outpatient information systems. This individual coordinates the interdisciplinary teams involved in each case (i.e., finance, clinical departments, and pharmacy), is responsible for ensuring all necessary clinical corrections are made promptly, and each case is validated before closure to ensure that documentation is complete and accurate to support patient safety and continuity of care.
Responsibilities
- Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
- Corrects and resolves incorrect documentation issues within CHRISTUS enterprise clinical systems such as fraudulent chart use, multiple patients' information in one health record, and one patient with two or more records/encounters to maintain a complete and correct legal health record for each patient.
- Makes independent decisions on how best to address critical registration and documentation errors impacting patient safety and direct clinicians, ancillary & clinical departments on the necessary actions that must be taken to mitigate.
- Facilitates incorrect emergent registrations through the Contact Move process on inpatients and emergency department patients, interfacing with and directing multiple stakeholders as to the appropriate actions to take to quickly resolve data quality issues because of wrong patients being registered.
- Ensures accurate correction of clinical information between patients and systems, confirming corrections with the senior members of the team. Precision and accuracy are mandatory due to the high risk to patient safety.
- Maintains an in-depth understanding of data flow between the EHR, various repositories, and ancillary systems. Attain a general understanding of site-level information systems, both active and historical (legacy).
- Develops and maintains good communication with a wide variety of internal and external professional relationships to accomplish departmental and hospital objectives.
- Communicates with customers throughout the chart correction process, utilizing e-mail, phone calls, in-basket messaging, and Service Now updates.
- Participates in the analysis and correction of large-scale system errors as a result of the conversion, build issues, and clinical system bugs.
- Works with CHRISTUS facilities to ensure smooth and coordinated correction to patient clinical data to ensure accuracy and prevent disruption to patient care and minimize the impact on patient safety.
- Acts as a liaison between patients, clinicians, and practice/clinical staff to ensure that incorrect data is identified, charting errors are communicated to the parties identified in the chart correction policy, erroneous data is corrected, and is verified that the clinical information was updated completely and correctly. Conduct patient interviews to verify clinical and demographic information to assist in record integrity corrections.
- Communicates with clinicians, health care providers, and HIM Applications Team to provide critical and complex information on how to report and correct health record documentation, often in an urgent timeframe.
- Processes patient requests for amendments to the clinical information in a patient’s medical record, per federal (HIPAA) guidelines. Coordinates with CHRISTUS entities on multi-site corrections to facilitate a seamless (one patient, one record) patient experience. Makes addendum in the electronic record by following proper procedures and notifying all departments affected.
- Documents outcomes of the chart correction process according to organizational policies. Advise clinicians, HIM staff, and other customers on HIM procedures and assist in the resolution of incorrect documents and documentation-related issues.
- Provide feedback to HIM Operations for changes and enhancements related to HIM/Identity functionality. Assists the Identity team members in preparing detailed specifications and proposals for modifying the existing system when the solutions follow clear precedence. Works with the EMPI and HIM Operations teams to review, test, and implement new functionality for the HER.
- Assists in the development and implementation of policies and procedures to streamline the workflow of Chart Correction, increase productivity, and maintain consistency with current practice.
- Assists in training new Chart Correction employees and team members regarding Hospital and Departmental policies and procedures.
- Coordinates with the EMPI Team when a duplicate or deactivation is identified or created during a chart correction.
- Monitors and replies to all communication sent to the Chart Correction team within the email box, in-basket, and Service Now queue.
- Performs other duties as needed.
- Uses the CHRISTUS Health values to govern decisions, actions, and behaviors.
Education/Skills
Job Requirements:
- Bachelor of Science Degree in Nursing preferred.
Experience
- 3-5 years of healthcare experience as an RN in an electronic health record environment is required.
- Understanding of clinician needs and workflows in an acute care setting is required.
- Epic experience preferred.
- Health Information Management experience preferred.
- Experience as a Super User or implementing an electronic health record preferred.
Licenses, Registrations, or Certifications
- RN License in the state of employment or compact required.
Work Type
Full Time
EEO is the law - click below for more information:
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf
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