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“A clinical documentation specialist plays a pivotal role in the healthcare system by meticulously ensuring that medical record documentation is both accurate and comprehensive. This responsibility is crucial because these records are foundational to patient care, serving as the primary source of information for healthcare providers to make informed decisions.”

A clinical documentation specialist, also known as a documentation improvement specialist, ensures that official standards of healthcare recording and documentation are upheld. The discipline is closely related to the field of medical claims billing in the sense that both fields rely on a deep knowledge of medical codes.

Clinical documentation professionals use government-sponsored professional coding systems such as ICD-10-CM and CPT to report on patient records, diagnoses, the quality of their care, and any other services provided.

Daily tasks include reviewing and analyzing health documents to properly record relevant diagnoses and procedures for patients, staying abreast of federal and state regulations, keeping informed of changes in treatment modes and new procedures, and performing coding when physician documentation is vague or missing.

Apart from these essential duties, clinical documentation (CD) specialists work collaboratively with physicians and other healthcare professionals to ensure that clinical information in the medical record is accurate. They code the appropriate utilization, clinical severity, outcome, or quality of the health record and ensure what is called “compliant reimbursement” of patient services.

Certified clinical documentation specialists are a class of healthcare professionals in high demand. There is now an ever-growing need for the specialized, certified skill set of clinical documentation specialists. These jobs exist at all levels of healthcare. Overall, certified clinical documentation specialists are critical to the healthcare industry’s profiling, reimbursement, quality measure reporting, and quality control standards consistently upheld.

Check out how to join this growing career, including information about academic programs, certifications, and salary.

Richard Martin is a health information management instructor at Weber State University. In addition to his academic role, he continues to provide medical records consulting services to skilled nursing facilities throughout Utah, demonstrating his commitment to improving healthcare operations. Before his role at Weber State, he served as an operations manager, overseeing multiple engineering teams, ensuring a seamless 24/7 operation, and consistently meeting established metrics.

He holds a master’s degree in health/healthcare administration from Saint Joseph’s University and a bachelor’s degree in health information/medical records administration from Weber State University. He is a Registered Health Information Administrator (RHIA), Microsoft Certified Solutions Expert (MCSE), Cisco Certified Network Professional (CCNP), and Certified Cisco Network Associate (CCNA).

Healthcaredegree.com: What is something you wish the public understood about clinical documentation specialists?

Martin: A clinical documentation specialist plays a pivotal role in the healthcare system by meticulously ensuring that medical record documentation is both accurate and comprehensive. This responsibility is crucial because these records are foundational to patient care, serving as the primary source of information for healthcare providers to make informed decisions.

A specialist must have a keen eye for detail and a thorough understanding of medical terminology to ensure that each entry accurately reflects the patient’s clinical status. Compliance with regulatory requirements is non-negotiable, as medical records must adhere to stringent Federal and State regulations to avoid legal repercussions and ensure the integrity of the patient data.

HealthcareDegree.com: What advice would you give to aspiring clinical documentation specialist students?

Martin: Never stop learning. As medical sciences and regulations continually advance, professionals must remain proactive in updating their knowledge and skills. This commitment to lifelong learning ensures that the integrity of the medical documentation you manage remains uncompromised, safeguarding patient care and compliance.

Also, fostering strong, effective communication with physicians is essential to refining the documentation query process. This involves mastering skills such as active listening, clear and concise communication, and collaborative problem-solving. By engaging with physicians constructively, you can significantly enhance the quality and accuracy of documentation.

There are several career options for clinical documentation specialists. These include positions in medical centers, research facilities, private practices, university laboratories, colleges, dental offices, psychiatric offices, medical billing centers, insurance companies, and other healthcare facilities. Each job provides training to bring clinical documentation professionals up to speed on their specific requirements.

Most professionals can enter this field with a certificate or associate’s degree. Certificate programs are often administered by national certification agencies or through community colleges. Most certificate programs are non-degree programs and don’t count as college credits. The most common associate’s degree earned is one in health information management. While a bachelor’s degree or higher is not required for this field, it can help with employability or advancement opportunities.

Regarding admissions requirements for students interested in a career in clinical documentation, criteria vary depending on whether the program is hosted by a college or professional association.

Diploma, certificate, and associate degree programs generally require the submission of one’s secondary school transcripts, an application fee, and proof of English proficiency for ESL students.

Students considering careers in clinical documentation should pay close attention to a school’s accreditation status before applying. Accreditation ensures that a school’s standards (or those of a specific educational program) have met peer-reviewed guidelines.

There are several programmatic accreditation bodies which approve educational programs related to clinical documentation in healthcare.

The Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) offers accreditation for health information management programs. The American Health Information Management Association (AHIMA) offers accreditation as well through its Professional Certificate Approval Program.

Although not all diploma, certificate, and degree programs for aspiring clinical documentation specialists have received recognition from one of the above bodies, students should ensure that their institution of choice at least has regional accreditation. A full list of reputable regional accreditation entities is available on the Council for Higher Education Accreditation (CHEA) website.

The health information technology technical certificate from Arkansas Tech University can be extremely useful to an aspiring clinical documentation specialist. In just one year, students can gain the necessary skills to understand health records’ origin, use, content, and format. The 2018/2019 graduating class from this program had an impressive 100 percent pass rate on the Registered Health Information Technician (RHIT) exam.

Required classes include fundamental computer operation, medical terminology, health data content and structure, human anatomical structure, information systems in healthcare, pharmacology, disease processes, and healthcare management. The program comprises 36 credits.

Arkansas Tech University also offers a 60-credit in-person health information technology associate degree program. Graduates of these programs can take up roles such as data analysts, medical billing specialists, medical coders, and medical compliance specialists.

• Accreditation: Higher Learning Commission (HLC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

Students in Baltimore City College’s associate of applied science degree in health information technology will have the necessary skills to work as clinical documentation specialists. All participants in this program learn how to collect and maintain health data, maintain confidentiality, and adhere to local, state, and federal regulations.

Aspiring clinical documentation specialists will find this program particularly useful as there is an emphasis on medical coding, including a CPT-4 Coding Principles course and another one in ICD-10-CM Coding Principles and Practice. Admission requirements include biology, medical terminology, writing, and anatomy and physiology prerequisite coursework.

This program’s 64-credit curriculum includes courses such as health information systems, medical terminology, anatomy and physiology, medical jurisprudence and ethics, developmental psychology, healthcare management supervision, computer applications in healthcare, modern elementary statistics, and health and life fitness.

• Accreditation: Middle States Commission on Higher Education (MSCHE); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
• Expected Time to Completion: Four semesters

Through the University of Hawaii Community Colleges’ Leeward Community College, three degrees and certificates in health information technology are offered: an associate’s of applied science, a certificate of achievement, and a certificate of competence. Any of these programs will suffice for entry-level work as a clinical documentation specialist.

The associate’s degree (61 credits) takes two years to complete, the certificate of achievement (31 credits) takes two to three semesters, and a certificate of competence (16 credits) can be completed in one intense semester. All courses in every program must be passed with a C or higher to count. However, only the associate’s degree program qualifies students to sit for the Registered Health Information Technician (RHIT) exam.

The curriculum includes courses such as healthcare delivery systems, health data, records, and documentation, business information systems, medical terminology, anatomy and physiology, introduction to diagnosis coding, introduction to procedure coding, disease pathology and pharmacology, reimbursement methodologies, and quality management.

• Location: Pearl City, HI
• Accreditation: Accrediting Commission for Community and Junior Colleges (ACCJC) of the Western Association of Schools and Colleges (WASC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

Bishop State Community College offers a two-year associate’s in applied science in health information technology. Students who complete this program can also earn a short certificate in medical coding, which can be an asset when starting a career as a clinical documentation specialist.

Required coursework includes general education classes and courses in medical terminology, diagnostic and pharmacology, pathophysiology and pharmacology, health data content and structure, operational standards for health care delivery systems, medical coding systems, and business statistics.

The only admission requirement for this program is graduation from high school. Applicants must submit official transcripts and have at least a 2.0 GPA if they have completed college coursework.

• Accreditation: Southern Association of Colleges and Schools Commission on Colleges (SACSCOC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

The goal of the associate’s of applied science in health information technology at National Park College is to produce competent professionals ready for entry‑level work in health information. With two required medical coding classes, this degree is an excellent choice for those pursuing a career as a clinical documentation specialist. Students also must complete two professional practice courses where they will gain hands‑on experience working with real health information.

Graduates of this program can transfer the credits they have earned to the University of Arkansas at Fort Smith to complete a bachelor’s of applied science in management and leadership.

The 63-credit curriculum includes courses on health data content, legal aspects of health information, fundamentals of medical science, basic health statistics, healthcare quality management, reimbursement methods, and computers in healthcare.

• Location: National Park, AR
• Accreditation: Higher Learning Commission (HLC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
• Expected Time to Completion: Two years

This CDEO (Certified Documentation Expert – Outpatient) online clinical documentation improvement training course prepares students for entry‑level work as clinical documentation specialists.

The clinical documentation expert outpatient certification is targeted toward professionals with prior medical coding or auditing knowledge, preferably at least two years. The course is taught by leading AAPC instructors and requires textbooks and reference materials on AMA’s Current Procedural Terminology (CPT), ICD-10‑CM, and the Healthcare Common Procedure Coding System (HCPCS).

• Location: Online
• Accreditation: Joint Commission for the Accreditation of Health Organizations (JCAHO)
• Expected Time to Completion: Varies, self-directed

AHIMA’s clinical documentation improvement certification offers a module‑based approach to certification as a CDI professional. There are no academic prerequisites, and students can access the site and its resources for one full calendar year after application and payment. Four courses must be completed.