How to Become a Clinical Documentation Specialist

What is a Clinical Documentation Specialist?

A clinical documentation specialist works to ensure proper record-keeping and manages the information, reports, notes, and correspondence produced by healthcare professionals in the course of their duties.

The purpose of their work is to ensure that data from multiple sources and of a variety of types is complete and consistent, stored in logical and searchable ways and the language of healthcare professionals is accurately translated into the language of medical coding. This will ensure information can be easily retrieved, transmitted, or cross-referenced as required, whether that is to support or review the treatment of an individual patient, ensure payment for medical treatment, defend against litigation, or to provide meaningful statistics to drive improvement or support medical research.

What is a Clinical Documentation Improvement Specialist?

A clinical documentation improvement specialist is charged with the responsibility for enhancing, improving and, in some cases, redesigning, how medical information is recorded and stored. The purpose of their role is to deliver improved outcomes in terms of recording efficiency, data quality, data accuracy, or data usability.

In some cases, this may take shape as a reactive program of changes related to the introduction of new regulations or requirements, in others it may be a proactive activity intended to contribute to wider organizational goals such as increased efficiency or a stronger focus on contribution to clinical research projects.

What Does a Clinical Documentation Specialist Do?

The primary task of a clinical documentation specialist is to review medical records daily for incomplete, conflicting, or ambiguous information. Where they identify an omission or a discrepancy, their role is to contact the medical team to resolve the gap or data conflict. For example, a physician may note CHF in a patient’s record to denote congestive heart failure. There are three different reimbursement rates for CHF under Medicare rules so in this case, the clinical documentation specialist would need to contact the physician to find out which type of CHF was involved in order to update the record correctly and ensure the hospital receives the correct reimbursement.

The clinical documentation specialist will then follow up on the queries they have raised to ensure they have been answered and the physician’s responses are documented. In smaller healthcare settings, clinical documentation specialists may also be responsible for adding the information in medical records into the hospital database themselves or, in a larger facility, they may liaise with medical coders who perform this role.

On occasion, clinical documentation specialists may undertake deep-dive reviews on a particular category of medical records to address a specific challenge or goal. For example, if the data suggests that less than the optimum amount of recompense is being obtained from insurance companies regarding treatments for breast cancer treatment, they may review all the relevant files to identify whether any improvements can be made to the coding or data collection for that category of treatment. If they do identify any problems or opportunities for enhancements, the clinical documentation specialist may then be responsible for implementing and measuring the effectiveness of improvement strategies.

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Clinical documentation specialists may also be responsible for interrogating the higher-level data held in the hospital databases to produce statistics and graph trends on disease and recovery, highlight patterns, and to report or present these findings to physicians or hospital managers.

Educating and updating healthcare professionals about documentation requirements also falls within the remit of the clinical documentation specialist. They may find themselves designing and running workshops or producing awareness or guidance material to inform healthcare colleagues if regulations or coding requirements change, if opportunities to improve the recording of information have been identified, or simply to refresh and remind colleagues of their responsibilities.

Where Does a Clinical Documentation Specialist Work?

A clinical documentation specialist usually works within the records area of a hospital or another medical setting such as a physician’s office or nursing care facility.  These professionals typically work with a computer in an office environment rather than on a ward or in a treatment room.

This allows easy access to hospital systems and any paper records and offers the ability to communicate in person with healthcare colleagues. In larger facilities, clinical documentation specialists may be required to work on a shift basis to ensure timely throughput of medical records and availability of the specialist knowledge of these professionals at all times.

Can a Clinical Documentation Specialist Work From Home?

As healthcare records and reports make the transition to becoming predominantly electronic rather than paper-based, there is an increasing trend towards these professionals performing their duties remotely. This is most achievable in larger records departments where the duties of a clinical documentation specialist can be divided according to whether role-holders are onsite or working remotely.

The daily review of medical files, raising and following up queries with clinicians, and entering coding into the hospital database are all tasks that lend themselves to remote working. Similarly, undertaking deeper dives into categories of files, performing data analysis tasks, and producing reports, can all be completed anywhere there is an internet connection and a computer.

However, presenting findings to groups of physicians or hospital managers, running education sessions with healthcare colleagues, and working creatively with groups of colleagues to identify and deploy improvement strategies are activities that are more difficult to perform remotely and should be carried out onsite.

What are the Requirements to Become a Clinical Documentation Specialist?

Educational Requirements

The majority of clinical documentation specialists are drawn from either a nursing background or a health information background.

To become a licensed Registered Nurse requires either an associate degree in nursing (ADN) or a bachelor’s degree in nursing (BSN) followed by a pass on the NCLEX-RN licensure examination. An ADN can usually be completed in two years, and a BSN can generally be completed in four years. Typical admission requirements vary by state and institution, however minimum requirements for entry to a nursing major typically include a GPA of between 2.0 and 3.5, a passing score on an academic readiness test such as the ATI TEAS, and an SAT score (or equivalent ACT score) of above 1100. Entry to nursing programs is typically selective and competitive.

The curriculums for an ADN and a BSN are very similar; the major difference is that the BSN curriculum includes more underpinning theory and conceptual information than the ADN. The academic curriculum includes health sciences such as anatomy, approaches to patient care, nursing ethics, and introductions to psychology and sociology. The practical curriculum incorporates development of psychomotor skills and preparation for common nursing scenarios. These skills are usually developed in a simulation laboratory. Clinical rotations follow this in healthcare settings and some form of preceptorship or mentoring from an existing registered nurse or nurse educator. Both programs prepare nurses who are ready to take up their first roles in the healthcare team.

Students who would prefer to develop a specialism in health information, have the option of either a two-year associate degree (AAS) in health information technology (HIT) or a four-year bachelor’s degree (BS) in health information management (HIM). Students considering applying to health information technology programs may be able to improve their chances of obtaining a place on their chosen course by taking high school courses in health, computer science, math, and biology.

The curriculums for the AAS and BS both include topics such as anatomy and physiology, data analysis, medical terminology and transcription, coding procedures, health regulations, and informatics. Some programs include an internship. The bachelor’s curriculum incorporates additional courses focused upon business and management principles, information policy and systems, record maintenance, and cost-benefit analysis as it relates to information processing. Many bachelor’s programs can be undertaken online.

Work Experience Requirements

Clinical documentation specialist positions typically require 2-5 years of prior work experience in health information management, health information technology and/or nursing. Registered nurses usually seek entry-level employment at community health facilities and hospitals. Candidates with a degree in health information management may gain prior work experience by working as a medical coder and/or records technician in a doctor’s office, clinic, medical office, nursing home, etc.

Certification Requirements

Certification requirements vary from state-to-state and are preferred for health information technicians and administrators. Registered Nurses must be licensed, but certification is optional.

There are three main bodies in the USA that offer certification for clinical documentation specialists. The first is the American Health Information Management Association (AHIMA). Holders of a health information management associate degree are eligible to take AHIMA’s Registered Health Information Technician (RHIT) certification exam while bachelor’s graduates are eligible to take AHIMA’s Registered Health Information Administrator (RHIA) certification exam.

The second certification organization is the Association of Clinical Documentation Improvement Specialists (ACDIS) who offer a Clinical Documentation Specialist (CCDS) credential. To qualify to take this exam, applicants need two years of professional documentation experience. Lastly, the American Academy of Professional Coders (AAPC) also offers professional certification.

Certifications are maintained by earning continuing education credits, usually between 20-30 credits must be evidenced in a two year period. The requirements for Registered Nurses vary by state, but typically RNs must evidence a similar number of continuing education credits as well as demonstrate a minimum number of patient contact hours to renew their license every two years.

What Does It Take to Become a Clinical Documentation Specialist?

  • Working knowledge of how healthcare professionals operate – clinical documentation specialists need first-hand day-to-day knowledge of how healthcare professionals work, so they can ensure documentation systems are appropriate and stored information will meet their needs. Typically, this knowledge can only be gained by working as a healthcare professional, or closely alongside healthcare professionals for a period.
  • Familiarity with medical vocabulary – clinical documentation specialists, need to know and understand the vocabulary of anatomy and physiology, pathophysiology, pharmacology, and associated medical terminology and commonly used abbreviations to interpret the information they are processing correctly.
  • Ability to interpret medical documentation – accurate interpretation of a diverse range of medical reports and documents including medication administration records, radiology reports, laboratory reports, and emergency room documentation is required as a key competency of the role.
  • Healthcare coding expertise – a detailed understanding of the coding methods used in the healthcare professions and how these can be optimized to ensure appropriate reimbursement is an essential requirement for a clinical documentation specialist.
  • Knowledge of healthcare regulations, protocols and statistical methodologies – knowledge of federal, state, and private payer regulations, applicable organizational policies and procedures, and standard statistical methodologies such as Case Mix Index (CMI) and Diagnosis Related Groups (DRG) are required. For example, clinical documentation specialists need an in-depth understanding of the coding and reimbursement regulations under the Inpatient Prospective Payment System (IPPS).
  • IT literate – role-holders must be familiar and comfortable with the primary IT systems used in their healthcare environment.
  • Attention to detail– it is the responsibility of the clinical documentation specialist to ensure all medical documentation is as precise, concrete, and as detailed as possible. Incomplete or imprecise documentation may result in a wide range of undesirable outcomes including inefficiency, inappropriate or unsafe treatment of patients and inability to recoup costs from patients or insurance companies.
  • Data measurement and analysis – in order to develop and implement strategies to improve clinical documentation performance, role-holders require the skills to identify and implement different measurement methodologies, create and analyze spreadsheets, create forecasting data, and draw appropriate conclusions.
  • Communication skills – clinical documentation specialists will frequently need to interact with busy healthcare professionals to implement changes to record-keeping, clarify details, and provide requested records. The ability to communicate with both concision and precision while maintaining positive relationships is a crucial requirement of the role.
  • Maintain confidentiality – a clinical documentation specialist is the steward of a large amount of sensitive personal information. It is essential they are willing to maintain the confidentiality and security of that data.

How Much Does a Clinical Documentation Specialist Make?

The Bureau of Labor Statistics (BLS) reports the median salary for a medical records and health information technician was $38,040 in May 2016. Records technicians working in professional and scientific services were earning the most while those working in physician’s offices were earning the least.

However, this is a field which is developing and expanding rapidly, and pay data from other sources such as indicates the average pay for a clinical documentation specialist may be somewhat higher than the BLS suggests at $68,861. also indicates the salary range overall is $48,368 – $92,651 and Registered Nurses with experience in acute care may command the highest salaries.

What is the Job Outlook for Clinical Documentation Specialists?

According to the Bureau of Labor Statistics, the employment of health information technicians is likely to grow by 13% between 2016 and 2026. This is faster than the average for all occupations but slightly lower than the average for healthcare occupations overall, which is projected to grow 18% from 2016 to 2026

This growth is driven by an aging population who need more medical services, the shift to maintaining health records electronically, and the continuing complexity and financial inter-relationships between patients, healthcare providers, government healthcare organizations such as Medicare, and insurance companies.

Against this backdrop, the role of the clinical documentation specialist as the guardian of the quality and accuracy of stored medical data continues to grow in importance and value to healthcare providers. The job outlook for these professionals is positive and continues to trend upwards.

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