Clinical Documentation Specialist Job Description

Clinical documentation specialists work for hospitals or medical service providers to monitor the quality of medical records and documents. This includes making sure records contain a sufficient amount of information about diagnoses, treatments, and follow-up required. Clinical documentation specialists deal primarily with doctors, nurses, and other health professionals to clarify issues and add missing information to ensure policies and regulations are met. The hours for this job vary depending on the organization, though there may often be long shifts and some larger facilities may require a clinical documentation specialist to be on duty at all times, so the position is shared. People well suited to becoming clinical documentation specialists are strong communicators who are organized and detail oriented.

 

Clinical Documentation Specialist Duties and Responsibilities

Based on job listings we analyzed, clinical documentation specialists’ duties typically involve:

Collecting Patient Information

Clinical documentation specialists collect information from medical teams about patients’ diagnoses and enter it into a computer database for security. They conduct research and perform administrative duties as well.

Assess Medical Documents for Accuracy

Clinical documentation specialists assess all medical documents for accuracy and ensure that records are systematically organized so that they can be easily located at a later date.

Check that Clinical Documents Comply with Laws

Clinical documentation specialists check that all medical documents comply with federal laws in terms of how they are composed and stored. They are responsible for assessing systems and recommending strategies for improving the record keeping process to provide better service to staff and patients alike.

Prepare Written Reports

Clinical documentation specialists work with staff to interpret reports to identify health-related patterns and assist in addressing health problems in patients, as well as preparing written reports for public health officials who evaluate the healthcare facilities.

Meet with Clinical Staff to Explain Reports

Clinical documentation specialists meet with clinical staff to explain reports. This involves applying their knowledge of medical terminology and procedures to evaluate clinical documents and address any issues in the reports.

 

Clinical Documentation Specialist Skills and Qualifications

Typically, employers require an associate’s degree and several years’ experience in a similar role, as well as the following abilities:

  • Detail oriented – clinical documentation specialists work with medical documents and clinical assessments to identify problems or trends, so having good attention to detail is important to ensure that nothing of importance is missed or ignored
  • Interpersonal skills – excellent interpersonal and communication skills are necessary to remain polite, courteous, and professional while dealing with a variety of different people in different roles
  • Critical thinking skills – clinical documentation specialists analyze medical information to provide better service to patients and to apply medical knowledge to evaluate clinical documents, requiring effective problem-solving skills
  • Confidentiality – clinical documentation specialists work with confidential information on a daily basis, so they should have knowledge of privacy laws and maintain a level of confidentiality to protect patients.
  • Training – clinical documentation specialists train information specialists on the proper methods of documentation and maintaining medical records properly, and teach medical coders standard procedures to follow when composing medical documents

 

Clinical Documentation Specialist Education and Training

The minimum requirement to become a clinical documentation specialist is an associate’s degree in health information technology. These programs often include computer training, how to access medical record information systems, and medical coding and terminology. More advanced qualifications include a bachelor’s degree in health services, public health, or care administration. Some employers may require work experience in addition to a formal qualification. Graduates from health information technology associate’s programs can also earn AHIMA’s Registered Health Information Technician (RHIT) credential as well. Clinical documentation specialists are expected to continue their education to stay up to date with the latest laws governing patient information.

 

Clinical Documentation Specialist Salary and Outlook

The median annual salary for clinical documentation specialists is nearly $69,000. Clinical documentation specialists in the 10th percentile earn around $48,000 annually, while the highest paid earn close to $93,000 a year. Some companies have bonus structures which can offer up to $6,000 in additional income.

Location and level of experience impact the pay level; many employers offer dental plans and medical insurance as part of their benefits package. The Bureau of Labor Statistics predicts the growth rate for this sector to grow by 13 percent through 2026.

 

Helpful Resources

We’ve collected some of the best resources to help you develop a career as a clinical documentation specialist:

The Clinical Documentation Improvement Specialist’s Guide to ICD-10 – This revised version of a trusted reference guide explains the ICD-10 documentation and clinical indicators those working as a clinical documentation specialist may come across. It covers the latest tested tips and tools, as well as strategies to implement successful programs.

Clinical Documentation Improvement Specialists Handbook – This book aims to be an inclusive reference for clinical documentation specialist professionals. It covers the fundamentals of coding, querying physicians, and helps to develop strong interdepartmental communication.

ACDIS – The Association for Clinical Documentation Improvement Specialists site is packed with useful information that will help anyone beginning a career in this field, or those who want to stay up to date with the latest developments. The resource library, in particular, is a handy collection of whitepapers, webcasts, and more.

AHIMA Journal – The American Health Information Management Association’s blog highlights best practices in health information management and the emerging issues in the field, such as privacy, security, and accuracy of patient information.

 

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