The provider documentation specialist (PDS) is responsible for providing provider documentation and education related to concurrent review of the health record. The goal of the PDS is to assess the technical accuracy, specificity, and completeness of provider documentation and ensure the documentation explicitly identifies all pertinent findings and conditions present during the time of service.
This position utilizes specialized knowledge, judgment, and nursing skills necessary to assess data and plan, provide and evaluate care appropriate to the physical and developmental age of assigned patients.
The nurse uses clinical skills to coordinate, document and communicate all aspects of the utilization management program. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
Provides leadership by working cooperatively and effectively with physicians, ancillary staff and other administrative and support personnel in maintaining the standards of professional nursing practice in the multidisciplinary clinical setting.
Formulates a plan of care, including the discharge plan, utilizing assessment data and patient, family and health team input. Initiates a plan of care based on patient-specific needs, assessment data and the medical plan of care.
Evaluate the patient's and family's response to care and teaching, and revises the plan of care as needed. Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members. Evaluates patient's response and the effectiveness of patient teaching.
Performs a complete nursing assessment on patients as soon as possible after admission, but within 8 hours from the time of admission. Documents this information within the Admission Assessment Record.
Formulates a plan of care, including the discharge plan, utilizing assessment data and patient, family and health team input. Initiates a plan of care based on patient-specific needs, assessment data and the medical plan of care. Goals for patient are realistic, measurable and developed in conjunction with the patient/family.
The Admissions Nurse is responsible for the coordination of clinical activities through developing and sustaining an environment that promotes excellence in clinical practice and customer satisfaction, while striving for optimal efficiency, productivity and utilization of all resources.