Clinical Documentation Specialist

A clinical documentation specialist, also known as a documentation improvement specialist, is responsible for ensuring 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. 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 that have come into 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 to consistently be upheld.

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

Clinical Documentation Specialist Degree & Career Types

There are a number of 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 of these jobs provides training to bring its clinical documentation professionals up to speed on its 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. 

Admissions Requirements for Clinical Documentation Programs

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. 

For example, Labouré College’s CDI (clinical documentation improvement) program requires a $25 application fee, documentation of high school graduation, GED completion (or another state-approved equivalency credential), and official college transcripts, if applicable. 

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.

Clinical Documentation Program Accreditation

Students considering careers 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) has 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 of 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.

On-Campus Clinical Documentation Specialist Education Programs

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, the legal aspect of health information, and pharmacology. Admission requirements include a high school diploma, proof of registration in selective service for men, immunization records, and a completed application. 

  • Location: Ozark, AR
  • Duration: Three semesters
  • Accreditation: Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
  • Tuition: $258 per credit 

Baltimore City Community College

Students in the associate’s of applied science 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. 

  • Location: Baltimore, MD
  • Duration: Four semesters
  • Accreditation: Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
  • Tuition: $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, 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 takes two years to complete, the certificate of achievement takes two to three semesters, and a certificate of competence can be completed in one intense semester. All courses in every program must be passed with a C or higher in order to count. However, only the associate’s degree program qualifies students to sit for the Registered Health Information Technician (RHIT) exam.

  • Location: Pearl City, HI
  • Duration: Two years
  • Accreditation: Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
  • Tuition: $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 as well as courses in anatomy, medical terminology, organizational improvement, and medical coding. 

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
  • Duration: Two years
  • Accreditation: Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
  • Tuition: $324 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. 

  • Location: National Park, AR
  • Duration: Two years
  • Accreditation: Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
  • Tuition: $137 per credit

Online or Hybrid Clinical Documentation Specialist Education Programs

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 the textbooks and reference materials on AMA’s Current Procedural Terminology (CPT), ICD-10-CM, and the Healthcare Common Procedure Coding System (HCPCS).

  • Location: Online
  • Duration: Varies, Self-Directed
  • Accreditation: Joint Commission for the Accreditation of Health Organizations (JCAHO)
  • Tuition: $1,695 for CDEO course; $2,330 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. There are four courses that must be completed.

  • Location: Online
  • Duration: One year
  • Accreditation: National Commission for Certifying Agencies (NCCA)
  • Tuition: Contact AHIMA for a customized assessment

Labouré College

The online certificate in clinical documentation improvement from Labouré College offers an innovative course of study on clinical documentation that teaches the fundamentals of documentation management, data operations, and health information technology. 

This is one of the only programs in the country that prepares students for both main national certification exams: CDIP (Certified Documentation Improvement Practitioner) from AHIMA and CCDS (Certified Clinical Documentation Specialist) from ACDIS (Association of Clinical Documentation Integrity Specialists). 

  • Location: Online
  • Duration: One year
  • Accreditation: New England Commission of Higher Education
  • Tuition: $375 per credit

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 in order 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 completion of 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. 

  • Location: Ft. Lauderdale, FL
  • Duration: Two years
  • Accreditation: Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
  • Tuition: $17,099.60 tuition for the entire program

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.  

  • Location: Online
  • Duration: 16 months
  • Accreditation: Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
  • Tuition: $514 per credit 

How Long Does it Take to Become a Clinical Documentation Specialist?

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.

How To Become a Clinical Documentation Specialist – Step-by-Step Guide

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 a 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.

What Do Clinical Documentation Specialists Do?

A clinical documentation specialist, also known as a documentation improvement specialist, is responsible for ensuring that official standards of healthcare recording and documentation are upheld. The job is closely related to medical claims billing in the sense that 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 

Clinical Documentation Specialist Certifications & Licensure

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.

How Much Do Clinical Documentation Specialists Make?

The Bureau of Labor Statistics (BLS 2021) reports that the clinical documentation-related field of medical records and health information technicians is set to grow 8 percent between 2019 and 2029, adding 29,000 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 318,010 medical records specialists in the united states, according to the BLS (May 2020):

  • Average annual salary: $48,270
  • 10th percentile salary: $28,800
  • 25th percentile salary: $34,810
  • 50th percentile (median): $44,090
  • 75th percentile salary: $57,840
  • 90th percentile: $73,370

Clinical Documentation Specialist Career Alternatives

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

Become a Health Data Analyst

Data that is gathered in health care 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 that can 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 health care 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 on clinical trials is the clinical research coordinator, who is responsible for most of the 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

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.

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