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What does a Clinical Documentation Specialist do?

Learn all about Clinical Documentation Specialist duties, skills and much more. Get expert advice on how to become a Clinical Documentation Specialist.

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Brenna Goyette
Certified Professional Resume Writer, Career Expert

Published 4 min read

A Clinical Documentation Specialist is responsible for improving the overall quality of a medical record. They do this by ensuring that the documentation accurately reflects the patient's condition and care.

Clinical Documentation Specialist job duties include:

  • Reviewing clinical documentation for completeness and accuracy
  • Identifying opportunities for improvement in clinical documentation
  • Working with clinicians to improve documentation
  • Ensuring compliance with documentation guidelines
  • Abstracting data from clinical documentation
  • Coding diagnoses and procedures using ICD-10-CM/PCS and CPT
  • Entering data into electronic health records
  • Providing feedback to clinicians on documentation quality
  • Generating reports on documentation quality metrics
  • Participating in quality improvement initiatives

Clinical Documentation Specialist Job Requirements

A Clinical Documentation Specialist (CDS) is a healthcare professional who specializes in the accurate documentation of a patient's medical record. They are responsible for ensuring that all clinical documentation meets regulatory requirements and is consistent with the patient's clinical status. A CDS typically has a bachelor's degree in health information management or a related field, and many have certification from the American Health Information Management Association (AHIMA). CDSs must have strong clinical knowledge and experience working with electronic health records (EHRs).

Clinical Documentation Specialist Skills

  • Medical terminology
  • Anatomy and physiology
  • Clinical documentation
  • ICD-10 coding
  • Medical billing
  • Medical records
  • EHR systems
  • Computer skills
  • Strong writing skills
  • Attention to detail
  • Critical thinking

Related: Top Clinical Documentation Specialist Skills: Definition and Examples

How to become a Clinical Documentation Specialist

A Clinical Documentation Specialist (CDS) is a medical professional who specializes in the accurate documentation of patient care. They are responsible for ensuring that all clinical documentation meets required standards and is complete, accurate, and compliant with regulations.

To become a CDS, one must first earn a bachelor’s degree in health information management or a related field. Many CDS programs also require certification from the American Health Information Management Association (AHIMA). After completing their education and training, CDSs must pass a national exam to earn their credential.

Once they have earned their credential, CDSs can find employment in hospitals, clinics, or other healthcare facilities. They may also work for insurance companies or government agencies. Some CDSs choose to work as consultants, helping healthcare organizations to establish and maintain effective clinical documentation practices.

The job of a CDS is important because accurate clinical documentation is essential to good patient care. CDSs play a vital role in ensuring that all members of the healthcare team have the information they need to provide the best possible care for each patient.

Related: Clinical Documentation Specialist Resume Example

Related: Clinical Documentation Specialist Interview Questions (With Example Answers)