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

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

It’s a lot to keep track of, which is why major hospitals and private practices sometimes count on clinical documentation specialists to keep things running smoothly. If you’re considering pursuing the healthcare 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, also sometimes referred to as a medical records specialist, organizes the information for each patient seen by a medical establishment. Patients provide some of this information on the forms they fill out when they first go to a new doctor’s office, while medical professionals create others.

These forms cover things like basic information and mental or physical health conditions that healthcare providers need to know. This is a big task, which is why specialists usually work together.

Each clinical documentation specialist is responsible for complying with HIPAA requirements and other confidentiality regulations while making sure the healthcare providers involved are on the same page. The specialist handles this by reviewing health 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 clinical documentation specialist 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 clinical documentation personnel can cross paths with patients.

Basic Clinical Documentation Specialist Duties

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

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

What Does a Clinical Documentation Specialist Do?

An average day in the life of a clinical documentation specialist 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 doctors, specialists, and other personnel
• Following up on previously unanswered queries or delayed answers
• Making sure the hospital or healthcare facility gets proper Medicare reimbursement
• Contacting a patient’s insurance company if necessary

If you become a clinical documentation specialist, 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.

How Much Does a Clinical Documentation Specialist Make?

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

The median wage for a medical records specialist is $48,780 per year as of May 2022, according to the Bureau of Labor Statistics.¹ That means approximately half of the people in this field earned more, and half earned less.

Keep in mind that wages 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 in income, too. So can location, education, years of experience, and other factors.

Note: UMA’s graduates in the 2021-2022 cohort of its Health Information Management diploma and degree programs reported to UMA that they earned a median hourly wage that is approximately at or slightly higher than the BLS’s lowest decile. Earnings information was typically obtained by a self-report from the graduate, and occasionally from the graduate’s employer or other sources.

How to Become a Clinical Documentation Specialist

If you enjoy the thought of being a clinical documentation specialist, it’s time to start thinking about what it takes to become one. There typically isn’t a “clinical documentation specialist” program, but there are certain things you can do to obtain the education needed to work in this type of role.

Go to School

The first step toward many healthcare careers is a diploma or degree. This provides a basic understanding of the healthcare field, healthcare terminology, and the billing and coding process. It also helps you develop the skills needed for this role.

A health information management program can help you get started. Your coursework during this area of study may cover topic areas such as:

• Health information and healthcare records
• Healthcare computer applications
• Data quality and management
• Reimbursement and the revenue cycle
• Medical terminology
• Pathophysiology and pharmacology

You can find different types of degree programs that offer studies in these areas. Typically, the role of clinical documentation specialist requires a postsecondary certificate to enter this role, but some employers may prefer an associate degree.²

Build Your Skills in the Workforce

While not always required, you may become a more competitive job candidate if you gain some direct work experience. One way to get this experience is to find a degree program that offers a practicum, internship, or externship as part of its curriculum. This allows students to develop skills in real-world settings under supervision and apply the concepts they’ve learned.

You can also gain experience through working in related roles, like front-desk positions within a healthcare office setting. If you have a background in patient-facing positions, you may be able to apply the firsthand knowledge you gained.

Optional: Become a Certified Clinical Documentation Specialist

Earning your certification can also make you a more competitive candidate when applying for a clinical documentation specialist job. Certification exams and requirements vary by state and employer.²

A relevant certification for a clinical documentation specialist is the Registered Health Information Technician (RHIT) credential offered by the American Health Information Management Association (AHIMA). To sit for this exam, you must first complete a health information management program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM), such as the online Health Information Management associate degree program offered by Ultimate Medical Academy (UMA).

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

Benefits of Becoming a Clinical Documentation Specialist

Taking the steps needed to become a clinical documentation specialist could lead you to a career in this field. Here are just a few reasons why.

Making a Difference in the Lives of Patients

The role this healthcare professional plays in a patient’s life can be critical. Without someone to check the accuracy of a diagnosis or ask about conflicting data, a patient may not get the treatment they need.

Doctors don’t always have time to go through every line of paperwork and coding. That’s where you could come in – as a clinical documentation specialist, you can help fill in the gaps to ensure other healthcare professionals have the information they need to provide quality patient care.

Professional Growth Opportunities

Your healthcare journey doesn’t have to stop once you’ve become a clinical documentation specialist. What you do next can depend on your work experience, additional education or certification, and other factors.

For example, after you gain experience, you may decide to pursue a position that involves managing a team of health information specialists (additional education may be required). At the very least, you can continue to learn new information and skills relevant to this healthcare role.

Take Your First Steps Toward a Clinical Documentation Specialist Career

Now that you know what a clinical documentation specialist is and what they do, you have a better idea of whether this role is a good fit for you. If you decide that it is, earning a degree in health information management can help prepare you for this role.

UMA offers an online Health Information Management associate degree program. This program can be completed in 18 months³ and, since it is offered online, it enables you to study and complete your coursework on the days and times it is convenient for you.

Set schedules required for on-site externship/practicum courses in select programs and in all programs, coursework deadlines are set by instructors.
Coursework is online except for an on-site externship/practicum in select programs.

UMA learners enjoy a variety of student services to help them succeed not only during their schooling but also job search assistance. From Student Finance advisors who can help you navigate the financial aid process to Career Services, a team of individuals dedicated to helping you prepare for your job search, UMA strives to take care of you so you can better care for others.

Contact Admissions today to talk about what we can do for you!