Clinical Documentation Specialist Certification and Degree Program Info

Clinical documentation specialists organize and manage health information data. Aspiring clinical documentation specialists often enroll in an associate's or a bachelor's degree program in health information management.

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Essential Information

Both associate's and bachelor's degree programs fulfill the education requirements to take the Certified Clinical Documentation Specialist examination through the Association of Clinical Documentation Improvement Specialists. Candidates who are qualified might also become registered professionals. With coursework that addresses epidemiology, infectious disease, and medical science, programs may consist of laboratory components, classroom lectures, and internship experiences. Online study options may also be available.

Both programs have similar enrollment requirements. Both a two-year and four-year degree will need students to have a high school diploma or GED. The bachelor's program, however, usually requires prerequisite coursework in anatomy and physiology, medical terminology, statistics, and computer application, a physical, and current immunization records.


Associate of Science in Health Information Technology

The associate's program prepares students to manage personal, medical, and diagnostic information while adhering to a patient's rights of privacy and confidentiality. Other areas of focus include healthcare laws and ethics, anatomy and physiology, and disease processes. The curriculum combines health science and information technology courses to provide students with a background in the management of medical information systems. Studies in medical terminology familiarize students with language used in medical settings, including terms for examinations, treatments, and procedures. Courses in computer applications prepare students to utilize computer programs to maintain databases and electronic patient health records. Topics of discussion might include:

  • Reimbursement
  • Health information theory
  • Digital information
  • Pathology
  • Infectious disease

Bachelor of Science in Health Information Management

Health information managers use information systems used to develop, collect, and maintain patient files and records of diagnoses, procedures, and financial information. Coursework in health informatics programs introduce students to healthcare management systems, including studies in computers, data management, and systems design. Other areas of study include human resource management, the protection of electronic health information, billing, coding, and financial planning. Course topics might include:

  • Epidemiology
  • Retrieval systems
  • Drug classification systems
  • Data mining
  • Medical science

Popular Career Options

Graduates find employment in a variety of settings, including hospitals, physicians' offices, and insurance companies. Popular career options for graduates include:

  • Clinical documentation specialist
  • Health information technician
  • Medical coder

Employment Outlook and Salary Information

According to the U.S. Bureau of Labor Statistics (BLS), medical records and health information technicians held 189,930 jobs in 2015, with most positions existing in hospitals and private doctors' offices (www.bls.gov). The BLS projected that the demand for these professionals would grow 15% between 2014 and 2024 due to an aging population that was expected to need more medical testing and the reliance of electronic records keeping in the medical industry. The median annual salary of these workers as of May 2015 was $37,110, per BLS figures.

Continuing Education

Graduates with one year of professional experience could be eligible to sit for the Certified Clinical Documentation Specialist (CCDS) examination administered by the Association of Clinical Documentation Improvement Specialists (www.hcpro.com). Certified professionals must complete 20 continuing education credits every two years to maintain certification. Graduates can also enroll in a bachelor's degree program to improve job outlook and boost salary potential.

In addition to CCDS certification, graduates of a bachelor's degree program could also earn the Registered Health Information Administrator (RHIA) credential offered through the American Health Information Management Association (AHIMA). This advanced certification applies to those interested in advancing a career into a medical management or administrator position. AHIMA also offers certification options for coding specialists for those in general medical, hospital or clinician environments. Continuing education is required to maintain all AHIMA certifications (www.ahima.org).

To become a clinical documentation specialist, students typically complete an associate's or bachelor's degree in health information technology or health information management, respectively. Professional certification is available depending on a student's experience and level of education.

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