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How to Become a Clinical Documentation Specialist

Learn how to become a clinical documentation specialist. Research the career requirements, licensure information, and experience required for starting a career in clinical documentation.

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Should I Become a Clinical Documentation Specialist?

Clinical documentation specialists manage clinical trial and service documents. They ensure accuracy and quality among medical coders, doctors, nurses, and other healthcare staff. They maintain charts, medical records, and reports and solve any issues involving documentation.

Clinical documentation specialists, like other types of medical records and health information technicians, work full-time. Such specialists work primarily during regular business hours, with some exceptions possible. The majority work in hospitals, clinics, or laboratories where medical clinical trials are taking place.

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Career Requirements

Degree Level Associate's or bachelor's degree
Degree Field Nursing, health information management, health information technology
Experience 2-5 years
Certification and Licensure Certification is preferred for health information technicians and administrators; RNs must be licensed; clinical documentation certification is optional
Key Skills Excellent communication, leadership, interpersonal and organizational skills, ability to multitask; medical coding expertise
Salary (2014) $35,900 per year (Median salary for medical records and health information technicians)

Sources: Job postings from multiple employers (December 2012), National Council of State Boards of Nursing, Association of Clinical Documentation Improvement Specialists, U.S. Bureau of Labor Statistics (May 2014)

Step 1: Complete an Undergraduate Program

Because employers prefer to hire licensed nurses and registered health information professionals, students can pursue post-secondary education in either nursing or health information. Many schools offer associate's and bachelor's programs designed for aspiring RNs and LPNs; in some cases, prospective nurses may earn certificates or diplomas instead. Common course topics include mental health, patient assessment and professional ethics. Most programs include internships or field experiences.

Students who are more interested in health information can pursue an associate's degree in health information technology or a bachelor's degree in health information management. These programs may cover data analysis and informatics, anatomy, physiology, medical terminology and coding procedures. Internships are often part of the curriculum as well.

Success Tip:

  • Gain medical coding expertise. Employers often look for documentation specialists with knowledge of different coding systems. Students should make sure their chosen educational path includes coding coursework.

Step 2: Get Licensed or Certified

After completing an approved RN or LPN nursing program, graduates may qualify for licensure by taking an exam. Likewise, graduates of health information technology associate's programs can earn AHIMA's Registered Health Information Technician (RHIT) credential by passing a test. Earning a bachelor's degree in health information management can prepare students for credentialing as Registered Health Information Administrators (RHIA).

Step 3: Gain Work Experience

Prospective clinical documentation specialists usually need 2-5 years of work experience in nursing or health information management. According to the U.S. Bureau of Labor Statistics, RNs typically begin their careers as staff nurses in hospitals or community health settings. Common duties for nurses include obtaining medical histories, assessing patients and running tests.

RHITs can gain experience working as medical coders or records technicians in hospitals, doctors' offices, clinics or other healthcare settings. These professionals maintain the security of patients' records, code medical information and organize databases. RHIAs work in a variety of healthcare settings as well; they're responsible for overseeing all patient records and keeping up with current health information regulations.

Step 4: Become a Clinical Documentation Specialist

After gaining enough experience in nursing or health information, individuals may qualify for work as clinical documentation specialists. These professionals review records for coding accuracy, follow-up with physicians and inform medical staff members of updated documentation methods.

Step 5: Earn Certification

Clinical documentation specialists can earn voluntary certification through the Association of Clinical Documentation Improvement Specialists. The Certified Clinical Documentation Specialist (CCDS) credential provides proof of competency in the field and may lead to career advancement. To qualify for the CCDS exam, applicants need 1-2 years of professional documentation experience combined with college-level coursework.

Step 6: Maintain Licensure or Certification

In most cases, licensure or certification must be renewed after a certain period of time. For example, RNs often renew their licenses every two years, and completion of continuing education coursework may be required. RHIT and RHIA credentials are also good for two years; RHITs must earn 20 continuing education units during that time, while RHIAs need to earn 30 continuing education units.

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