I have extensive experience with various EHR systems, including Epic and Cerner. I ensure accurate documentation by regularly reviewing patient records for completeness and accuracy, adhering to coding guidelines, and collaborating with healthcare providers to clarify any ambiguous information. I also conduct training sessions for staff to enhance their understanding of documentation requirements and best practices.

I prioritize tasks based on the urgency and impact on patient care. I start by addressing documentation gaps that could affect reimbursement or clinical outcomes, followed by reviewing records flagged for errors or inconsistencies. I also allocate time for ongoing education and support for healthcare providers to ensure continuous improvement in documentation practices.

I foster effective communication by maintaining open lines of dialogue with healthcare providers, offering regular feedback on documentation, and providing education on the importance of accurate documentation. I also use collaborative tools like huddle meetings and email updates to keep everyone informed and engaged in the documentation improvement process.

I stay updated by regularly attending professional development courses, webinars, and conferences focused on coding and documentation. I also subscribe to industry publications and participate in online forums to stay informed about the latest guidelines and best practices. Additionally, I collaborate with peers and mentors to share knowledge and insights.

One successful project involved improving the accuracy of diagnosis coding in our ICU. By implementing a targeted education program for ICU staff and conducting regular audits, we were able to reduce the number of undercoded diagnoses by 20%. This not only improved reimbursement but also enhanced the quality of patient care by ensuring that all relevant diagnoses were accurately documented.