Clinical Documentation Specialist Review

Perth Children?s Hospital (PCH) and Neonatology (PCH&N) is Western Australia?s specialist paediatric hospital and trauma centre, providing medical care to infants, children, and adolescents 15 years of age or under. PCH&N has approximately 37,261 hospital admissions per year (based on data from the 2022-23 financial year). The Child and Adolescent Health Service is seeking an experienced Respondent to provide a review of clinical documentation (Review) and related practices to assess areas of opportunity for improvement at PCH&N. The result of this review will then inform the scope of implementation and the number of clinical documentation specialists required to optimise clinical documentation. The expected benefits would include: Complete and accurate documentation at the point of care, which overall improves the quality and safety of patient care and compliance against National Safety and Quality Health Service standards.Increased clinical coding efficiency and accuracy, resulting in optimised activity-based funding (ABF).Reduced risk of medico-legal and regulatory issuesAccuracy in reporting caseload complexity, resulting in quality metrics The Review includes: Phase 1: Review of PCH&N clinical documentation and related practices. Deliverable: A report outlining key findings of the review, with recommendations for establishing a Clinical Documentation Service at PCH&N, including anticipated benefits, improvements and opportunities derived through appropriate clinical documentation.Phase 2: Implementation of a clinical documentation service, including training and education of clinical documentation specialist/s, development of resources and training materials for clinical staff and clinical coders, and education and awareness training for clinical staff and clinical coders.Phase 3: Post implementation consultation and support (3-, 6- or 12-months post implementation).