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Documentation Specialist: Job Description & Requirements

Learn about the education and preparation needed to become a documentation specialist. Get a quick view of the requirements as well as details about training, job duties, and skills to find out if this is the career for you.

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Essential Information

Documentation specialists can be broken down into two main groups of professionals - clinical documentation specialists and technical writers. Clinical documentation specialists are employed in the medical field, and handle patient or medical records. Technical writers work in various fields and are tasked with creating industry-specific documents, such as manuals. Although requirements vary, these specialists generally need at least minimal experience in their respective fields.

Career Titles Clinical Documentation Specialist Technical Writer
Required Education Associate's degree in nursing Bachelor's degree in English or communications
Projected Job Growth* (2012-2022) 22%
(Medical records and health information technicians)
15%
Median Salary* (2014) $35,900
(Medical records and health information technicians)
$69,030

*Source: U.S. Bureau of Labor Statistics

Clinical Documentation Specialist

Clinical documentation specialists, also known as medical records and health information technicians, compile patient medical histories, records, and other health-related information. Clinical specialists typically work for healthcare facilities, but they may also work for government agencies.

Job Description

Job titles, such as medical coder or health information technician, may dictate job duties. The job duties of clinical documentation specialists may include classifying patient treatments for billing purposes, tracking patient cases, recording information, and compiling statistics on medical treatments. Clinical specialists typically use computer software to perform these functions.

Requirements

An associate's degree in nursing or a related field generally provides the appropriate training for this career. Students take a range of courses from patient care to pharmacology. Programs may also require students to complete a practicum, which allows them to apply their nursing skills within a healthcare facility.

Voluntary Certification

The U.S. Bureau of Labor Statistics (BLS) cites that aspiring clinical documentation specialists who have earned certification from a credentialing organization may enhance their job opportunities (www.bls.gov). A number of organizations, such as the American Health Information Management Association and the American Academy of Professional Coders, offer varying designations in the field. For example, aspiring health information technicians may become Registered Health Information Technicians, while those pursuing a career path as a medical coder may earn the title of Certified Professional Coder. Certification typically requires successful completion of a qualifying examination.

Salary Info and Job Outlook

The BLS indicated that medical records and health information technicians, such as clinical documentation specialists, earned a median annual salary of $35,900 in May 2014. The same source predicted that employment of such specialists will likely grow by about 22% between 2012 and 2022.

Technical Writer

Technical writers work with industry specialists to produce easy to understand documents for staff, consumers, and other parties. These professionals usually work in the information technology industry.

Job Description

Technical writers couple their industry knowledge and writing skills to produce manuals, guidelines, and other materials. They may also edit existing documents and keep records of any changes made. Technical writers may work with vendors and production managers to assemble materials for product descriptions and user manuals.

Requirements

The BLS reports that technical writers are generally required to have completed a bachelor's program in English, communications, or a related field. Although requirements for these majors differ substantially, students generally take courses in technical writing and writing techniques. Some industries may require technical writers to have field-specific training. For example, technical writers working for computer software developers may need some background in computer software engineering.

Salary Info and Job Outlook

According to the BLS, the median annual salary earned by technical writers in May 2014 was $69,030. The Bureau also projected that the employment of such writers would increase by 15% between 2012 and 2022, a rate consistent with the national average for all occupations.

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