The job description of a clinical documentation specialist requires a medical professional to work in an administrative capacity. Such specialists can work in hospitals, physician practices, clinics and other medical facilities.
A clinical documentation specialist has the task of managing the creation of clinical files and maintaining the files as part of a patient’s medical record.
Essential Duties and Responsibilities of a Clinical Documentation Specialist
- Collects information about patients’ diagnoses and enters it into computer databases.
- Assesses all patient medical documents to ensure accuracy.
- Tracks information on diseases.
- Educates medical coders and billers on standard procedures that must be followed when composing medical documents.
- Recommends strategies for improving record keeping processes.
- Ensures all clinical documents are in compliance with federal laws in terms of composition and secure storage.
- Analyzes medical information to assist healthcare staff in providing superior services for patients.
- Applies knowledge of medical terminology and medical procedures to properly evaluate clinical documents.
- Prepares written reports for public health officials who evaluate healthcare facilities.
- Interprets clinical reports to identify health-related patterns and assists in addressing patient health problems.
- Meets with clinical staff to explain reports.
- Ensures that records are kept in proper order so that patients’ health information can be easily located.
- Conducts research and performs administrative duties.
- Trains information specialists on proper methods of documentation and maintenance of medical records.
- Takes continuing education courses and stays up-to-date on changes in laws governing clinical documentation.
Required Knowledge, Skills and Abilities
- Must be highly detail oriented.
- Exceptional analytical and critical thinking skills.
- Excellent written and verbal communication skills.
- Must have superior organizational skills.
- Strong leadership skills.
- Must have excellent interpersonal skills.
- Must have good time management skills.
- Must have strong negotiation skills.
- Must have excellent computer skills and knowledge of software for database maintenance and electronic health record storage.
- Knowledge of clinical conditions and procedures, medical coding and basic documentation requirements.
- Knowledge of accepted quality assurance procedures.
- Knowledge of patient privacy laws.
Education and Experience
- Associate’s degree in Health Information Technology orApplied Sciences and a Licensed Practical Nurse or LPN designation.
- Bachelor’s degree in Health Information Technology and a Registered Nurse or RN designation.
- Master’s degree in Health Informatics or Health Information Management.
- Certified Clinical Documentation Specialist or CCDScredentials through the Association of Clinical Documentation Improvement Specialistsor ACDIS.
- Certification as a Registered Health Information Technician, or RHIT, from the American Health Information Management Association or AHIMA, or fromthe American Academy of Professional Coders, otherwise known as the AAPC.
- Must be able to work in a very fast-paced environment.
- Time will be spent looking at a computer screen and keyboarding.
- Must be able to view photographs of real surgical procedures.
- Must be able to effectively deal with physicians who are defensive about their documentation practices.
- Must be able to work normal business hours of 8:00a.m. to 5:00p.m. Monday through Friday and longer hours based on workload.
- Salaries range from $35,000 to $85,000 depending on the level of education, years of experience and location and size of the facility of employment.