Clinical Documentation Specialist

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, coding the appropriate utilization, clinical severity, outcome, or quality of the health record, as well as ensuring 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.

There are several clinical documentation specialist career options. 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 just 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.

In terms of admissions requirements for students interested in a career in clinical documentation, criteria vary depending on whether the program is hosted by a college or by a 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 a set of 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. 

Arkansas Tech University

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 the origin, use, content, and format of health records. 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 an in-person health information technology associate degree program made up of 60 credits. Graduates of these programs will be able to take up roles such as data analysts, medical billing specialists, medical coders, and medical compliance specialists.

• Location: Ozark, AR
• Accreditation: Higher Learning Commission (HLC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
• Expected Time to Completion: Associate degree (24 months); certificate (12 months)
• Estimated Tuition: $136 per credit

Baltimore City Community College

Students in the associate of applied science degree in health information technology at Baltimore City College 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 prerequisite coursework in biology, medical terminology, writing, and anatomy and physiology.

The 64-credit curriculum of this program includes courses such as health information systems; medical terminology; anatomy & physiology; medical jurisprudence & ethics; developmental psychology; healthcare management supervision; computer applications in healthcare; modern elementary statistics; and health and life fitness, among others.

• Location: Baltimore, MD
• 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
• Estimated Tuition: In-state ($110 per credit); out of state ($280 per credit)

University of Hawai’i Community Colleges – Leeward Community College

There are three degrees and certificates offered for health information technology through the University of Hawai’i Community Colleges’ Leeward Community College. They are 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)
• Expected Time to Completion: Two years
• Estimated Tuition: Resident ($248 per credit); non-resident ($357 per credit)

Bishop State Community College

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 to have graduated from high school. If applicants have already completed college coursework, they must submit official transcripts and have at least a 2.0 GPA.

• Location: Mobile, AL
• Accreditation: Southern Association of Colleges and Schools Commission on Colleges (SACSCOC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
• Expected Time to Completion: Two years
• Estimated Tuition: Resident ($176 per credit); out-of-state ($303 per credit)

National Park College

The goal of the associate of applied science in health information technology at National Park College is to produce competent professionals who are 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 such as health data content; legal aspects of health information; fundamentals of medical science; basic health statistics; health care 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
• Estimated Tuition: Garland County residents ($110 per credit); out-of-county residents ($120 per credit); out-of-state residents ($157 per credit); international residents ($222 per credit)

American Academy of Professional Coders

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 knowledge of medical coding or auditing, 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
• Estimated Tuition: $1,095 for CDEO course; $1,395 for complete CDEO training package

American Health Information Management Association (AHIMA)

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

• Location: Online
• Accreditation: N/A
• Expected Time to Completion: One year
• Estimated Tuition: Contact AHIMA for a customized assessment

Broward College

The associate’s of science in health information technology at Broward College also includes coding and billing coursework. This two-year degree is offered in a hybrid online and in-person format. The health information technology courses are offered in a strict sequence that students must adhere to to complete their education on schedule. General education coursework, required for the associate’s degree, is more flexible and can be taken online, in-person, or on weekends and in the evenings.

Upon completing this program, students are eligible to sit for the Registered Health Information Technician (RHIT) exam, which can be useful in a career as a clinical documentation specialist.

As part of the program, students will delve into topics such as electronic medical records and technology; health data concepts; health information systems; health records law; health statistics; introduction to health science; pathophysiology and pharmacology; performance improvement; reimbursement methodology; and supervision & organizational life. The program consists of 70 credits.

• Location: Ft. Lauderdale, FL
• Accreditation: Southern Association of Colleges and Schools Commission on Colleges (SACSCOC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
• Expected Time to Completion: Two years
• Estimated Tuition: In-state ($8,664.60 total); out-of-state ($17,099.60 total)

DeVry University

Students who need a flexible clinical documentation specialist program will find what they are looking for at DeVry University. In as little as 16 months, students can complete an online associate of applied science in health information technology. Topics covered in this program include health insurance, reimbursement, record information, and legal and regulatory issues.

DeVry also offers a bachelor’s degree in technical management with a specialization in health information management which allows students who earn their associate’s at DeVry to seamlessly continue their studies.

Made up of 67 credits, the program includes courses such as basic medical terminology; introduction to health services and information systems; international classification of diseases coding; current procedural terminology coding; legal and regulatory issues in health information; health insurance and reimbursement; and pathopharmacology.

• Location: Online
• Accreditation: Higher Learning Commission (HLC; Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
• Expected Time to Completion: 16 months
• Estimated Tuition: $514 per credit

Weber State University

Weber State University’s online associate of applied science degree in health information technology (HIT) prepares students to succeed in this growing field of information management and healthcare coding. This AAS program is an excellent stepping stone between a certificate in healthcare coding and a health information management bachelor’s degree. Based on the 2020-2021 academic year, 100% of Weber State University’s HIT program graduates passed the RHIT certification examination on their first attempt.

The curriculum of this program includes courses such as healthcare privacy & security; diagnosis coding; ambulatory & physician office coding; ICD-10-PCS coding; healthcare database management & security; computer applications in health care; and introduction to quality improvement in health care.

Graduates of this program will be ready to work in various healthcare settings such as medical clinics and hospitals, insurance companies, home health agencies, mental health facilities, skilled nursing facilities, software vendors, public health agencies, and health maintenance organizations.

• Location: Ogden, UT
• Accreditation: Northwest Commission on Colleges and Universities (NWCCU); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
• Expected Time to Completion: Two years
• Estimated Tuition: $291 per credit hour

The road to becoming a documentation improvement specialist varies. Expect a minimum of one year to attain a postsecondary award in a clinical documentation specialization. Allot enough time to complete programs, up to perhaps three years, as some are on predetermined schedules and others are completed at the student’s pace.

Students pursuing a bachelor’s degree in health information technology or a related field might need up to five years to complete, including certification.

Becoming a clinical documentation specialist, as mentioned above, should take students a minimum of one year and up to five years after high school, depending on the educational path chosen, certifications needed, and clinical and industry experience required.

Step 1: Graduate From High School (Four Years)

As a high school student, a focus on classes in English and language arts, algebra, chemistry, physics, psychology, biology, geometry, speech, and anatomy/physiology can help to build a solid foundation for pursuing a certification in clinical documentation improvement.

Step 2: Earn a Postsecondary Nondegree Award or Certification (One Year or More)

Earn certification or postsecondary nondegree award in clinical documentation (CDI) or as a documentation improvement practitioner (CDIP) to qualify yourself as a professional in the field. AHIMA’s aforementioned CDI certification is a great place to begin.

Step 3: Gain Industry Experience (At Least One Year)

One way to advance a career as a clinical documentation specialist is to gain work experience in the health and medical records industry. This helps a candidate prepare for more advanced certifications, gaining the experience necessary for more leadership responsibilities, which are typically requisite in candidates being considered for positions in upper management or as clinical directors.

Step 4: Earn an Associate or Bachelor’s Degree (Optional, One to Four Years)

Earning an associate of science or arts (AS, AS, AAS) or a bachelor of science or arts (BS, BA) in health information management or health information technology can increase one’s earnings and open doors to upper-level positions. It should be made clear that college degrees of any kind are not necessary for those interested in a clinical documentation specialist career.

A clinical documentation specialist, also known as a documentation improvement specialist, ensures that official standards of healthcare recording and documentation are upheld. The job is closely related to medical claims billing because both fields rely on a deep, studious recall of medical codes.

Clinical documentation jobs exist at all levels of healthcare, and as paperwork (or its digital equivalent) will never go away, certified clinical documentation specialists are critical to healthcare businesses so that their profiling, reimbursement, quality measure reporting, and quality control standards are consistently upheld.

Apart from these essential duties, CD specialists collaborate with other healthcare professionals to ensure that clinical information in the medical record is accurate, code the appropriate utilization, and ensure what is called “compliant reimbursement” of any and all patient services.

Some critical skills for clinical documentation or clinical documentation improvement practitioners include:

• Working knowledge of basic computer programs
• Working knowledge of Microsoft Office Suite
• Typing
• Thorough knowledge of industry coding practices (e.g., ICD-10-CM) 
• Inpatient/outpatient coding skills
• Interpersonal skills
• Communications skills
• Chart review experience
• Electronic medical record (EMR) experience
• Clinical documentation specialization/improvement software experience
• Background in reporting

To become a clinical documentation specialist, you can become certified through either the Association of Clinical Documentation Integrity Specialists (ACDIS), featuring certifications for entry-level employees, or the clinical documentation improvement practitioner course of study via the American Health Information Management Association (AHIMA).

AHIMA offers one certification, while ACDIS hosts three: the Certified Clinical Documentation Specialist (CCDS), the Certified Clinical Documentation Specialist – Outpatient (CCDS-O), and an ACDIS-Approved CDI Apprentice Program.

The qualifications and certification procedures vary at each level of credentialing and are available on their websites.

The Bureau of Labor Statistics (BLS 2022) reports that the clinical documentation-related field of medical records and health information technicians is set to grow 7 percent between 2021 and 2031, adding 12,300 jobs. The BLS notes that the required entry-level education for a clinical documentation specialist is a postsecondary nondegree award.

Finally, here are the detailed salary data for the 187,720 medical records specialists in the united states, according to the BLS (May 2022):

• Average annual salary: $51,090
• 10th percentile salary: $31,710
• 25th percentile salary: $37,510
• 50th percentile (median): $47,180
• 75th percentile salary: $60,170
• 90th percentile: $75,460

Here are a few alternatives to a career as a clinical documentation specialist.

Become a Health Data Analyst

Data gathered in healthcare facilities on everything from patient care to expenses to staffing is synthesized and analyzed by health data analysts. This information is then put into reports to help healthcare managers make data-driven decisions to improve patient outcomes, facility management, and budgeting.

• Typical Education: Bachelor’s degree
• Licensing or Certifying Organization: American Health Information Management Association (AHIMA)

Become a Medical Transcriptionist

Many healthcare providers use audio recorders to dictate their chart notes. These recordings are then transcribed into chart notes by medical transcriptionists. Medical transcriptionists may transcribe the entire recording or may use software for the bulk of the transcription and then spot-check for errors.

• Typical Education: Associate or bachelor’s degree
• Licensing or Certifying Organization:  Association for Healthcare Documentation Integrity (AHDI)

Become a Clinical Research Coordinator

Clinical trials are complicated and need a lot of oversight. One essential team member in clinical trials is the clinical research coordinator, who is responsible for most administrative tasks in a clinical trial. Duties can include ordering supplies, ensuring the integrity of the data collected, recruiting trial participants, and managing the budget.

• Typical Education: Bachelor’s degree
• Licensing or Certifying Organization: Association of Clinical Research Professionals (ACRP), Society of Clinical Research Associates (SOCRA)

Kenneth Parker

Writer

Kenneth is a feature writer, poet, and musician living in the Pacific Northwest. His writing on remote work, education, and technology has been published by BustedCubicle.com, MedicalTechnologySchools.com, and other websites. His poetry, short fiction, and album reviews have appeared in Scifaikuest, Nanoism, and No Clean Singing. His background includes time spent as an associate editor, proofreader, private grammar instructor, freelance content editor, medical claims agent, and SEO consultant. He is a graduate of the University of Oregon, where he studied literature and worked as a composition tutor.