How Can I Become a Clinical Documentation Specialist?

Research what it takes to become a clinical document specialist. Learn about employment options, education and certification requirements to find out if this is the career for you. Schools offering Healthcare Management & Public Safety Leadership degrees can also be found in these popular choices.

What Do Clinical Documentation Specialists Do?

Clinical documentation specialists manage the health information data for medical and healthcare facilities. They evaluate patient records to make sure that they are accurate and complete, and then they input the information into databases and electronic health records, where it can be analyzed for quality assurance and insurance reimbursement purposes. Clinical documentation specialists are also responsible for ensuring that sensitive patient data remains secure and confidential.

The following chart provides an overview of what you need to know about entering this field.

Degree Required Certificate or associate's degree
Education Field of Study Anatomy; physiology; medical terminology; data systems
Key Responsibilities Analyze and categorize data for insurance and patient care; ensure quality, accuracy, accessibility and security of data; code and categorize patient information for insurance purposes
Certification Professional credentials available from the AHIMA, the AAPC and the ACDIS; often required or preferred
Job Growth (2014-2024) 15%* (medical records and health information technicians)
Median Salary (2015) $37,110* (medical records and health information technicians)

Source: *U.S. Bureau of Labor Statistics

What is a Clinical Document Specialist?

A clinical document specialist may also be referred to as medical biller or coder, medical coding specialist or medical records and health information technician, according to the U.S. Bureau of Labor Statistics (BLS). In this role, one of your central tasks would be to manage health information data for hospitals, physicians' offices and other healthcare facilities (www.bls.gov). This could include analyzing, coding, categorizing and maintaining data for insurance purposes, patient treatment and medical registries. The position involves working with the Electronic Healthcare Record (EHR) system.

What Education Will I Need?

You may be able to obtain a position as a clinical documentation specialist with either a postsecondary certificate or associate's degree. In general, course topics in certificate programs will include anatomy and physiology, classification and coding systems, medical terminology and healthcare statistics. You may also have coursework in computer systems and other database-oriented practices.

An Associate of Applied Science (A.A.S.) program usually consists of 60 units. First-year coursework generally includes anatomy and physiology, computer applications, medical terminology and healthcare documentation and ICD coding. Second-year coursework will usually include human diseases, medical transcription and an internship. You may also have classes that cover standard business communication and office practices.

Will I Need Certification?

Since certification requirements will vary from state-to-state, as reported by the BLS, you'll want to refer to the guidelines for the state within which you'd like to work. Professional certification appears to be preferred, so you may want to explore different certifications before choosing a specific program. The BLS indicates that Registered Health Information Technician (RHIT) certification from the American Health Information Management Association (AHIMA) is an option, as is designation from the American Academy of Professional Coders (AAPC).

The Association of Clinical Documentation Improvement Specialists (ACDIS) also offers the Clinical Documentation Specialist (CCDS) credential. The designation will prove that you have an understanding of anatomy, pharmacology, coding guidelines and insurance regulations.

Are There Opportunities for Advancement?

If you're interested in a 4-year degree, you may want to explore Bachelor of Science degree programs in health information management (HIM). Programs of this nature may prepare you for work in consulting firms, pharmaceutical companies, public health organizations and various healthcare facilities.

If you're interested in obtaining a master's degree in health information management, you may want to refer to the Commission on Accreditation for Health Informatics and Information Management's (CAHIIM) accredited program information (www.cahiim.org). According to CAHIIM, there are master's degree programs in health informatics (HI) and health information management (HIM). While both programs offer practical knowledge and experience, the HI tends to be research-based.

The HI program focuses on information systems, principles and technology as they relate to the health informatics field. The HIM program focuses on administrative issues, information policy and systems, record maintenance and cost-analysis issues related to information processing.

What Are Some Related Alternative Careers?

If you want to get an office job within a healthcare facility, you could also consider becoming a medical secretary. This job would involve basic clerical tasks like answering phones and scheduling appointments, but you might also assist with the collection of patients' medical history information. Although no formal training is required, it can help to complete a postsecondary certificate or associate degree program. Another healthcare office occupation of interest is a job as a medical transcriptionist. These professionals use specialized software to convert audio recordings made by doctors into text formats that can be input into electronic health records. You need to complete a postsecondary training program in order to get this job.

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:

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