CYNET_SYSTEMS_MAIN_LOGO.gif   CLINICAL DOCUMENTATION SPECIALIST ORIENTATION CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) Overview of DRG Program 1 2 3 4  
Definitions (DRG, CMI, ETC)  
System Access  
ICD9 Manual  
Able to locate diagnoses/procedures  
Identify CC/MCC  
Rating Stars (Click) DRG Expert 1 2 3 4  
Identify Surgical vs. Medicine DRGs - diagnoses, procedures.  
Identify DRGs within MDC  
Identify DRGs requiring MCC/CC  
Review MCC/CC list  
Rating Stars (Click) Quick Reference Guide 1 2 3 4  
Review coding guidelines  
Review MDC guides  
MCC/CC references  
Rating Stars (Click) Online Coding Reference Guide 1 2 3 4  
Coding Clinics  
Dictionaries (Merck, etc.)  
Faye Brown  
Rating Stars (Click) Chart Review Process 1 2 3 4  
CDIS software  
CDS worksheet  
Organized chart review process  
Adheres to policy and procedure re:  
chart review process  
Rating Stars (Click) Query Process 1 2 3 4  
AHIMA Query Compliance Document  
When to Query Information Sheet  
AHIMA guidelines followed   
when querying MDs  
Utilizes query forms correctly  
Communicates effectively/appropriatelywith MDs  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU    
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)