What Does a Clinical Documentation Specialist Do Day-to-Day?

August 21, 2018

What Does a Clinical Documentation Specialist Do Day-to-Day?

Have you ever thought about all the paperwork that goes along with doctors and nurses treating your medical needs? From dentist cleanings to annual checkups, not to mention serious accidents or major surgeries, medical offices typically have stacks of paperwork for their patients.

Patients fill out some of these forms when they first go to a new doctor’s office, while medical professionals create others. These forms cover things like basic information and specific medical conditions that medical providers need to know.

It’s a lot to keep track of, which is why major hospitals and private practices alike often count on a clinical documentation specialist team to keep things running smoothly. If you’re considering joining the medical field, this could be a good opportunity for you.

Here’s everything you need to know about a day in the life of a clinical documentation specialist – and how you can become one.

What is a Clinical Documentation Specialist?

A clinical documentation specialist (CDS) organizes the information for each patient seen by a medical establishment. This is a big task, which is why specialists usually work together.

Each CDS is responsible for complying with HIPPA requirements and other confidentiality regulations while making sure that the medical providers involved in a person’s treatment are on the same page. A CDS handles this by reviewing medical records, ensuring medical codes have been inputted correctly, and documenting the specifics necessary to provide a full analysis of a patient’s health.

Such a role involves teamwork between each CDS and the various doctors and specialists with whom they work. It also requires a knack for organization, strong communication skills, and the ability to work well under pressure. Empathy is also a good quality to have, since many CDS personnel cross paths with patients.

The Basic Duties

So, what does it mean to document specifics or review medical records? Put simply, a CDS has to make sure all the information gathered and recorded is accurate and detailed. They may go through every piece of paper and every line of medical code for each patient’s case.

When it seems like information is missing, or there is conflicting data, it’s often up to a CDS to fill in the blanks. These situations require the CDS to communicate with various departments to make sure a patient’s records are as accurate and in-depth as possible.

A Typical Day as a CDS

According to the American Nurses Association’s journal, an average day in the life of a CDS may look something like this:

  • Evaluating a certain number of patient records
  • Going through records for specificity and proper documentation
  • Inputting document queries into a system for physicians, doctors, specialists, and other personnel
  • Following up on previously unanswered queries or delayed answers
  • Making sure the hospital or physician’s office gets proper Medicare reimbursement
  • Contacting a patient’s insurance company if necessary

If you become a CDS, you can expect to be doing a lot of desk work and research. Your day-to-day will likely be spent inputting codes and double-checking values, with the occasional sorting and locating of certain paperwork.

Average Starting Salary

Here’s something most people ask themselves when they choose a new career path, regardless of it’s in the medical field or not: how much does this pay?

The median wage for a clinical documentation specialist is $39,180 as of May 2017, according to the Bureau of Labor Statistics. That means approximately half of the people in this field earned more than this salary, and half earned less.

Keep in mind rates may vary depending on whether you’re working for a public hospital or private organization. The department in which you work – like scientific research and professional services versus basic care – may play into your salary, too. So can location, education, years of experience, and other factors.

How Can You Become a Clinical Documentation Specialist?

If you enjoy the thought of being a CDS, it’s time to start thinking about what it takes to become one. There typically isn’t a “clinical documentation specialist” major in college, but there are certain things you can do to get your clinical documentation specialist education.

Go to School

The first step toward many medical careers is a degree. You typically need a basic understanding of biology, the medical field, medical terminology, and the billing and coding process.

Many students choose a health information track to get started. Your coursework during this study may include:

• Healthcare computer information systems
• Data quality and management
• Medical terminology
• Pathophysiology and pharmacology

You can find 2-year associate degree and 4-year bachelor’s degree programs that offer studies in these areas. Typically the role of clinical documentation specialist requires a bachelor’s degree, but some employers may accept a two-year associate degree in a related field.

Build Your Skills in the Workforce

While not always required, you can become a more competitive candidate for this role if you gain some direct work experience.

One way to get this experience is to find a degree program that offers a practicum or internship as part of its curriculum. Practicums allow students to develop skills in real-world settings under supervision. This helps you apply the concepts you’re learning to a work setting.

You can also gain experience through working in related roles, like front-desk positions within a medical office setting. If you have a background in nursing or patient care, you may be able to apply the firsthand knowledge you gained form working with patients. Some employers may even require a bachelor’s degree in nursing or a related patient care field.

Prepare for Your Certification

Earning your certification can also make you a more competitive candidate.

Certification exams and requirements vary by state and employers. Generally speaking, you have to take a certain number of continuing education credits within a specific amount of time to be considered eligible for certification, along with other eligibility requirements.

A relevant certification for a clinical documentation specialist is the Registered Health Information Technician (RHIT) exam offered by the American Health Information Management Association (AHIMA). To sit for this exam, you need to successfully complete a related program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and possibly meet other eligibility requirements.

This credential is not always required, but it can make you a more appealing potential hire for employers.

The Benefits of Being a CDS

The education, work, and certification process to become a CDS may sound daunting, but remember it can be a fulfilling and worthwhile career. Keep the following things in mind to motivate yourself to continue.

Making a Difference in the Lives of Patients

At the end of the day, this is why many people in the medical field choose this path. The role a CDS plays in a patient’s life can be critical.

Without someone to check for accuracy of diagnosis and ask about conflicting data, a patient may not get the treatment they actually need.

Doctors don’t usually have time to go through every line of paperwork and coding. They have to work on one patient in order to move on to the next person who needs their help.

That’s where you could come in – as a CDS, you can fill in the gaps to ensure everyone has the information they need to do the best work they can.

Growth and Opportunity to Learn New Skills

Your medical journey doesn’t stop once you’ve become a CDS. From there, you could end up managing a team of health information specialists, or at the very least, learn a new thing or two about the medical field. What you do next can depend on your work experience, additional education or certification, and other factors.

Think about it: working on patients’ documents means you’re likely to come across many different medical situations, especially if you work in a hospital. You can learn the codes and best practices for everything from a child’s stitches to an emergency c-section or even open-heart surgery.

Travel Opportunities

You may be able to find an opportunity to travel as a CDS. That’s right – you may not have to stay in the same place! If you find and qualify for a traveling CDS position, you could travel around the U.S. to help take care of patients.

Such a role sends you to hospitals and medical offices around the nation to document paperwork and work with various medical professionals. It can be exciting, interesting, and rewarding.

Take Your First Steps Toward a CDS Career

Now that you know what a clinical documentation specialist is and what they do, you can put your mind to it, get to work, and gain the necessary qualifications to become one.

To explore our Health Information Technology learning opportunities, click here.

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The views expressed herein are those of the author and do not necessarily reflect those of Ultimate Medical Academy.

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