Clinical Documentation Specialist Education and Career

Clinical documentation specialists record and safe-keep patient data in order to expedite care and provider reimbursement. Read about accredited training programs in this field at the certificate, associate's degree and bachelor's degree levels. Review the coursework in these programs, the certification options and the salary potential for clinical documentation specialists. Schools offering Healthcare Management & Public Safety Leadership degrees can also be found in these popular choices.

What You Need to Know

Clinical documentation specialists can train for their careers through a number of education options. You can complete a certificate or degree program through an accredited training facility and go on to acquire certification to improve your chances of employment in this competitive field.

Programs Certificates, associate's degrees and bachelor's degrees in health information management
Courses Medical terminology, anatomy and physiology, analyzing healthcare data, health informatics, legal aspects of health information, healthcare reimbursement, healthcare statistics
Job Growth (2016-2026)* 13% for all medical records and health information technicians

Source: *U.S. Bureau of Labor Statistics

What Education Is Required to Be a Clinical Documentation Specialist?

While there are no specific educational requirements for a career as a clinical documentation specialist, you may obtain training through an accredited program in health information management or technology. The Commission on Accreditation for Health Information and Informatics Management Education (CAHIIM) accredits a variety of college programs and provides an overview of required curriculum.

You may complete an undergraduate certificate program featuring a limited selection of health information coursework as well as required practicum experience. An Associate of Applied Science degree or a Bachelor of Science degree in health information management or technology can also provide you with appropriate training. Certain bachelor's degree programs require residency hours working under the supervision of an administrative professional.

How Will Program Coursework Prepare Me for a Career?

CAHIIM-accredited programs will provide you with a background in:

  • Anatomical and physiological terminology
  • Health information data structures
  • Information systems
  • Database security
  • Clinical classifications
  • International Classification of Diseases (ICD) numbers
  • Current Procedural Terminology (CPT) numbers
  • Reimbursement methods
  • Billing procedures
  • Statistical analysis

What Types of Certification Can I Obtain?

Clinical documentations specialists can earn a variety of relevant credentials, such as Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA) and Certified Coding Specialist (CCS). These credentials, along with the Certified Documentation Improvement Practitioner (CDIP) credential, are issued by the American Health Information Management Association. A Certified Professional Coder credential, issued by the American Association of Professional Coders, allows you to specialize in coding for a specific area of medicine and treatment. These credentials typically require that you meet a minimum amount of relevant education, work experience or both.

What Are My Career Prospects and Income Potential?

In 2018, PayScale.com reported that the majority of clinical documentation specialists earned between $48,533 and $93,212 annually. According to the U.S. Bureau of Labor Statistics, career opportunities for medical records and health information technicians is expected to increase by 13% from 2016-2026 (www.bls.gov). Improvements in technology should lead to an increased demand for professionals with advanced information technology skills.

To continue researching, browse degree options below for course curriculum, prerequisites and financial aid information. Or, learn more about the subject by reading the related articles below:

  • 1. Degree Options:
The schools in the listing below are not free and may include sponsored content but are popular choices among our users. Tuition and costs will vary across programs and locations. Be sure to always request tuition information before starting a program.

Popular Schools

  • Purdue University Global

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    • Master
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  • Grand Canyon University

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  • Colorado State University Global

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  • Johns Hopkins University

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  • The George Washington University

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  • Regent University

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  • Capella University

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  • Penn Foster

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  • Northcentral University

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  • Southern New Hampshire University

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