How to Become a Clinical Documentation Specialist


Clinical documentation specialists supervise service and clinical trials documents. As a clinical documentation specialist, you are responsible for making sure that medical coders, physicians, nurses and other healthcare workers maintain accuracy and quality when recording information. You will also be responsible for maintaining up-to-date medical charts, reports and histories and resolving documentation issues.

There are two ways that you can become a clinical documentation specialist – you can earn a bachelor’s in nursing and obtain experience as a licensed practical nurse (L.P.N.) or registered nurse (R.N.) or you can earn a bachelor’s degree in health information or a related field and acquire managerial experience.

Educational and Work Requirements

Although it is not required for you to be a registered nurse (R.N.), or licensed practical nurse (L.P.N.), many employers prefer that their clinical documentation specialist have a degree, licensure and/or certification in nursing and/or health information. Many colleges and universities offer an associate and bachelor degree in nursing.

In addition, some schools offer certificates and/or diplomas in nursing and/or health-related areas.

While in your program, you will be required to take a variety of health-related courses such as: patient assessment, mental health and/or professional ethics. You may also be required to complete a clinical internship in a healthcare facility.

If your interest lies in health information, you may want to obtain an associate’s (A.A.) degree in health information technology or a bachelor’s (B.S.) degree in health information management. If you decide to take this route, you will be required to take courses in: anatomy, data analysis, physiology, coding and medical terminology.

You will gain invaluable medical coding experience while in your clinical internship. Most employers prefer clinical documentation specialist who have extensive medical coding knowledge. It is very important that you take as many coding classes as possible while in your degree program.

  • Licensure

Once you have successfully completed your nursing program, you may be eligible for licensure.  If you have a degree in health information technology, you can be licensed as a registered health information technician and if you have a bachelor’s degree in health information management, you can be licensed as a registered health information administrator. In order you will need to complete all of the educational requirements and pass your state’s licensure exam.

  • Work Experience

In order to be a clinical documentation specialist you will need to have at least 2-5 years of prior work experience in health information management, health information technology and/or nursing. According to the U.S. Bureau of Labor Statistics (2013), registered nurses usually seek entry-level employment at community health facilities and hospitals. As a nurse, your main responsibilities are documenting patient medical histories, evaluating patients and performing tests.

As a registered health information technician, you can 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. Your main responsibility in this position is to secure patient medical records, code medical data and/or organize databases. You are also responsible for supervising patient records and following all health information regulations.

After gaining work experience in nursing and/or health information, you may be eligible to practice as a clinical documentation specialist. As a clinical documentation specialist, your main tasks will be to assess medical records for coding accuracy, follow-up with medical professionals and update documentation methods.

  • Certification

The association of clinical documentation improvement specialists can grant you voluntary certification. You may be eligible to take the certified clinical documentation specialist certification examination. In order to qualify for the certification exam, you will need a college degree and 1 to 2 years of clinical documentation experience. You will also need to renew your license and/or certification every 2 to 5 years.

Job Duties

As a clinical documentation specialist, you may be required to perform the following duties:

  • Maintain the quality of patient records
  • Endure that medical charts and records contain the correct information concerning patient diagnoses, care and treatment
  •  Monitor for accurate coding and billing procedures
  • Collaborate with nurses, physicians and other medical professionals to rectify issues, correct errors and/or add missing information
  • Educate records technicians and/or other medical professionals on how to improve documentation practices so that regulations and policies are followed

Salary Prospects

According to (2013), you can expect to earn between $40,000 and $86,000 per year. The U.S. Bureau of Labor Statistics (2013) states that medical records technicians, health information technicians and clinical documentation specialist can expect to earn approximately $35,000 per year.

Career Outlook

The job outlook for this field is positive. Job opportunities will be the greatest if you are certified in health information. The U.S. Bureau of Labor Statistics (2013) estimates that job growth in the area of medical records, health information and clinical documentation is expected to increase 21% by 2020. Job growth in this field will continue due to the aging baby boomer population and the need for more advanced medical care.

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