How to Become a Healthcare Documentation Specialist


Healthcare documentation specialists belong to a specific niche in the healthcare industry. They are professionals who can transcribe and edit medical reports that are produced using speech technology. Using quantitative and qualitative analytical methods, these specialists ensure that all documents, reports, results, studies and files pertaining to the patient are accurate, reliable, relevant, and comply by rules and regulations.

By listening to audio that is especially recorded by physicians or other healthcare professionals, a healthcare documentation specialist eventually makes an electronic record of it. This information is collected using specialized recording instruments and software. If you wish to have an office based career in the medical industry then you should work hard to become a healthcare documentation specialist and enjoy the work life you desire.

Education Requirements

Though healthcare documentation specialists do not directly treat or tend to patient needs, they need to be familiar with medical terms and scenarios. At the same time they must possess sharp academic and analytical skills. Command of the English language, familiarity with medical jargon and surroundings are basic requirements for those interested in this field. Much of this training can be provided through certificate programs and while on the job.

Academic exposure and relevant training are offered by community colleges, online learning programs and vocational programs. It is advised to opt for a program that has been recognized by the Association for Healthcare Documentation Integrity or the American Health Information Management Association. Employers may prefer candidates to have an Associate’s degree or a post-secondary certificate for an entry level position. With basic understanding and knowledge of medical terminology, much of the training and practical exposure can be obtained while working.

To constantly evolve and improve your marketability in this industry, it is important to strive for more advanced certifications and academic qualifications. For instance, after spending a minimum of 2 years in acute-care transcription or an equivalent niche as a registered medical transcriptionist, you can strive to become a certified medical transcriptionist. This may allow you to rise further up the ranks in the healthcare industry. Employers may prefer candidates who are familiar with advanced industry practices and regulations. Furthermore, advanced certification may guarantee academic intelligence and experience which is generally rewarded by employers in the form of greater compensation.

Job Duties

The generic job duties of a healthcare documentation specialist are listed below. Actual job duties will vary depending on industry standards, place of work and common practices. As a healthcare documentation specialist you can work in a variety of setups such as hospitals, clinics, pharmaceutical companies, medical research companies, insurance companies, and so on.

  1. Go over recorded audio data and transcribe it thereby preserving it
  2. Edit and complete audio data to provide proper structure and formation. At times recorded data contains references or short phrases to save time which need to be given structure
  3. Interpret and consolidate patient encounters that can add value to the case. Clinical insight is necessary for the case to move forward
  4. Ensure that medical records and supporting data are protected so that patient confidentiality is preserved at all times
  5. Collect medical records of patients to assist physicians and examiners
  6. Develop systems for archiving and storing medical records of patients, case documents and all supporting documents
  7. Develop a system for easy and simplified sorting and retrieval of documents for future reference
  8. Routinely ensure that the electronic system and database are well maintained and secured
  9. Check and double check that transcribed medical reports and other patient documents are accurate
  10. Ensure that all activities and standards are within compliance of laws and regulations
  11. Give structure to all data that is recorded by proper labeling, organizing, tabulating and archiving
  12. Ensure that all documents are created, handled and preserved by following the healthcare industry’s standardized numerical coding system

Career Outlook

One can say that the demand for healthcare documentation specialists may gradually increase over the coming years. This is because a large number of people are realizing the importance of preventative healthcare and are going for regular visits to the doctor. This has increase the need for healthcare documentation specialists to document such medical data.

The Bureau of Labor Statistics estimates that there will be a growth of 21% in the field of medical records and health information technicians during the period of 2010 to 2020. This translates to roughly 37,700 new jobs. Healthcare documentation specialists fall under the aforementioned category.

Salary Prospects

The average annual salary for healthcare documentation specialists is $60,000 ( According to another source, the average yearly salary for healthcare documentation specialists is $55,000 ( Experience plays an important role in this line of work and you will notice that as you gain market experience you may enjoy greater compensation.

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