“A clinical documentation specialist plays a pivotal role in the healthcare system by meticulously ensuring that medical record documentation is both accurate and comprehensive. This responsibility is crucial because these records are foundational to patient care, serving as the primary source of information for healthcare providers to make informed decisions.”
Richard Martin, MHA, RHIA, Health Information Management Instructor, Weber State University
A clinical documentation specialist, also known as a documentation improvement specialist, ensures that official standards of healthcare recording and documentation are upheld. The discipline is closely related to the field of medical claims billing in the sense that both fields rely on a deep knowledge of medical codes.
Clinical documentation professionals use government-sponsored professional coding systems such as ICD-10-CM and CPT to report on patient records, diagnoses, the quality of their care, and any other services provided.
Daily tasks include reviewing and analyzing health documents to properly record relevant diagnoses and procedures for patients, staying abreast of federal and state regulations, keeping informed of changes in treatment modes and new procedures, and performing coding when physician documentation is vague or missing.
Apart from these essential duties, clinical documentation (CD) specialists work collaboratively with physicians and other healthcare professionals to ensure that clinical information in the medical record is accurate. They code the appropriate utilization, clinical severity, outcome, or quality of the health record and ensure what is called “compliant reimbursement” of patient services.
Certified clinical documentation specialists are a class of healthcare professionals in high demand. There is now an ever-growing need for the specialized, certified skill set of clinical documentation specialists. These jobs exist at all levels of healthcare. Overall, certified clinical documentation specialists are critical to the healthcare industry’s profiling, reimbursement, quality measure reporting, and quality control standards consistently upheld.
Check out how to join this growing career, including information about academic programs, certifications, and salary.
Meet the Expert: Richard Martin, MHA, RHIA
Richard Martin is a health information management instructor at Weber State University. In addition to his academic role, he continues to provide medical records consulting services to skilled nursing facilities throughout Utah, demonstrating his commitment to improving healthcare operations. Before his role at Weber State, he served as an operations manager, overseeing multiple engineering teams, ensuring a seamless 24/7 operation, and consistently meeting established metrics.
He holds a master’s degree in health/healthcare administration from Saint Joseph’s University and a bachelor’s degree in health information/medical records administration from Weber State University. He is a Registered Health Information Administrator (RHIA), Microsoft Certified Solutions Expert (MCSE), Cisco Certified Network Professional (CCNP), and Certified Cisco Network Associate (CCNA).
Healthcaredegree.com: What is something you wish the public understood about clinical documentation specialists?
Martin: A clinical documentation specialist plays a pivotal role in the healthcare system by meticulously ensuring that medical record documentation is both accurate and comprehensive. This responsibility is crucial because these records are foundational to patient care, serving as the primary source of information for healthcare providers to make informed decisions.
A specialist must have a keen eye for detail and a thorough understanding of medical terminology to ensure that each entry accurately reflects the patient’s clinical status. Compliance with regulatory requirements is non-negotiable, as medical records must adhere to stringent Federal and State regulations to avoid legal repercussions and ensure the integrity of patient data.
HealthcareDegree.com: What advice would you give to aspiring clinical documentation specialist students?
Martin: Never stop learning. As medical sciences and regulations continually advance, professionals must remain proactive in updating their knowledge and skills. This commitment to lifelong learning ensures that the integrity of the medical documentation you manage remains uncompromised, safeguarding patient care and compliance.
Also, fostering strong, effective communication with physicians is essential to refining the documentation query process. This involves mastering skills such as active listening, clear and concise communication, and collaborative problem-solving. By engaging with physicians constructively, you can significantly enhance the quality and accuracy of documentation.
Clinical Documentation Specialist Degree & Career Types
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There are several career options for clinical documentation specialists. These include positions in medical centers, research facilities, private practices, university laboratories, colleges, dental offices, psychiatric offices, medical billing centers, insurance companies, and other healthcare facilities. Each job provides training to bring clinical documentation professionals up to speed on their specific requirements.
Most professionals can enter this field with a certificate or associate’s degree. Certificate programs are often administered by national certification agencies or through community colleges. Most certificate programs are non-degree programs and don’t count as college credits. The most common associate’s degree earned is one in health information management. While a bachelor’s degree or higher is not required for this field, it can help with employability or advancement opportunities.
Admissions Requirements for Clinical Documentation Programs
Regarding admissions requirements for students interested in a career in clinical documentation, criteria vary depending on whether the program is hosted by a college or professional association.
Diploma, certificate, and associate degree programs generally require the submission of one’s secondary school transcripts, an application fee, and proof of English proficiency for ESL students.
Clinical Documentation Program Accreditation
Students considering careers in clinical documentation should pay close attention to a school’s accreditation status before applying. Accreditation ensures that a school’s standards (or those of a specific educational program) have met peer-reviewed guidelines.
There are several programmatic accreditation bodies which approve educational programs related to clinical documentation in healthcare.
The Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) offers accreditation for health information management programs. The American Health Information Management Association (AHIMA) offers accreditation as well through its Professional Certificate Approval Program.
Although not all diploma, certificate, and degree programs for aspiring clinical documentation specialists have received recognition from one of the above bodies, students should ensure that their institution of choice at least has regional accreditation. A full list of reputable regional accreditation entities is available on the Council for Higher Education Accreditation (CHEA) website.
On-Campus Clinical Documentation Specialist Education Programs
The health information technology technical certificate from Arkansas Tech University can be extremely useful to an aspiring clinical documentation specialist. In just one year, students can gain the necessary skills to understand health records’ origin, use, content, and format. The 2018/2019 graduating class from this program had an impressive 100 percent pass rate on the Registered Health Information Technician (RHIT) exam.
Required classes include fundamental computer operation, medical terminology, health data content and structure, human anatomical structure, information systems in healthcare, pharmacology, disease processes, and healthcare management. The program comprises 36 credits.
Arkansas Tech University also offers a 60-credit in-person health information technology associate degree program. Graduates of these programs can take up roles such as data analysts, medical billing specialists, medical coders, and medical compliance specialists.
- Location: Ozark, AR
- Accreditation: Higher Learning Commission (HLC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
- Expected Time to Completion: Associate degree (24 months); certificate (12 months)
Baltimore City Community College
Students in Baltimore City College’s associate of applied science degree in health information technology will have the necessary skills to work as clinical documentation specialists. All participants in this program learn how to collect and maintain health data, maintain confidentiality, and adhere to local, state, and federal regulations.
Aspiring clinical documentation specialists will find this program particularly useful as there is an emphasis on medical coding, including a CPT-4 Coding Principles course and another one in ICD-10-CM Coding Principles and Practice. Admission requirements include biology, medical terminology, writing, and anatomy and physiology prerequisite coursework.
This program’s 64-credit curriculum includes courses such as health information systems, medical terminology, anatomy and physiology, medical jurisprudence and ethics, developmental psychology, healthcare management supervision, computer applications in healthcare, modern elementary statistics, and health and life fitness.
- Location: Baltimore, MD
- Accreditation: Middle States Commission on Higher Education (MSCHE); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
- Expected Time to Completion: Four semesters
University of Hawai’i Community Colleges – Leeward Community College
Through the University of Hawai’i Community Colleges’ Leeward Community College, three degrees and certificates in health information technology are offered: an associate’s of applied science, a certificate of achievement, and a certificate of competence. Any of these programs will suffice for entry-level work as a clinical documentation specialist.
The associate’s degree (61 credits) takes two years to complete, the certificate of achievement (31 credits) takes two to three semesters, and a certificate of competence (16 credits) can be completed in one intense semester. All courses in every program must be passed with a C or higher to count. However, only the associate’s degree program qualifies students to sit for the Registered Health Information Technician (RHIT) exam.
The curriculum includes courses such as healthcare delivery systems, health data, records, and documentation, business information systems, medical terminology, anatomy and physiology, introduction to diagnosis coding, introduction to procedure coding, disease pathology and pharmacology, reimbursement methodologies, and quality management.
- Location: Pearl City, HI
- Accreditation: Accrediting Commission for Community and Junior Colleges (ACCJC) of the Western Association of Schools and Colleges (WASC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
- Expected Time to Completion: Two years
Bishop State Community College
Bishop State Community College offers a two-year associate’s in applied science in health information technology. Students who complete this program can also earn a short certificate in medical coding, which can be an asset when starting a career as a clinical documentation specialist.
Required coursework includes general education classes and courses in medical terminology, diagnostic and pharmacology, pathophysiology and pharmacology, health data content and structure, operational standards for health care delivery systems, medical coding systems, and business statistics.
The only admission requirement for this program is graduation from high school. Applicants must submit official transcripts and have at least a 2.0 GPA if they have completed college coursework.
- Location: Mobile, AL
- Accreditation: Southern Association of Colleges and Schools Commission on Colleges (SACSCOC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
- Expected Time to Completion: Two years
The goal of the associate’s of applied science in health information technology at National Park College is to produce competent professionals ready for entry-level work in health information. With two required medical coding classes, this degree is an excellent choice for those pursuing a career as a clinical documentation specialist. Students also must complete two professional practice courses where they will gain hands-on experience working with real health information.
Graduates of this program can transfer the credits they have earned to the University of Arkansas at Fort Smith to complete a bachelor’s of applied science in management and leadership.
The 63-credit curriculum includes courses on health data content, legal aspects of health information, fundamentals of medical science, basic health statistics, healthcare quality management, reimbursement methods, and computers in healthcare.
- Location: National Park, AR
- Accreditation: Higher Learning Commission (HLC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
- Expected Time to Completion: Two years
Online or Hybrid Clinical Documentation Specialist Education Programs
American Academy of Professional Coders
This CDEO (Certified Documentation Expert – Outpatient) online clinical documentation improvement training course prepares students for entry-level work as clinical documentation specialists.
The clinical documentation expert outpatient certification is targeted toward professionals with prior medical coding or auditing knowledge, preferably at least two years. The course is taught by leading AAPC instructors and requires textbooks and reference materials on AMA’s Current Procedural Terminology (CPT), ICD-10-CM, and the Healthcare Common Procedure Coding System (HCPCS).
- Location: Online
- Accreditation: Joint Commission for the Accreditation of Health Organizations (JCAHO)
- Expected Time to Completion: Varies, self-directed
American Health Information Management Association (AHIMA)
AHIMA’s clinical documentation improvement certification offers a module-based approach to certification as a CDI professional. There are no academic prerequisites, and students can access the site and its resources for one full calendar year after application and payment. Four courses must be completed.
- Location: Online
- Accreditation: N/A
- Expected Time to Completion: One year
The associate’s of science in health information technology at Broward College also includes coding and billing coursework. This two-year degree is offered in a hybrid online and in-person format. The health information technology courses are offered in a strict sequence that students must adhere to to complete their education on schedule. General education coursework required for the associate’s degree is more flexible and can be taken online, in-person, or on weekends and evenings.
Upon completing this program, students are eligible to sit for the Registered Health Information Technician (RHIT) exam, which can be helpful in a career as a clinical documentation specialist.
As part of the program, students will delve into topics such as electronic medical records and technology, health data concepts, health information systems, health records law, health statistics, an introduction to health science, pathophysiology and pharmacology, performance improvement, reimbursement methodology, and supervision and organizational life. The program consists of 70 credits.
- Location: Ft. Lauderdale, FL
- Accreditation: Southern Association of Colleges and Schools Commission on Colleges (SACSCOC); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
- Expected Time to Completion: Two years
Students needing a flexible clinical documentation specialist program will find what they seek at DeVry University. In as little as 16 months, students can complete an online associate of applied science in health information technology. Topics covered in this program include health insurance, reimbursement, record information, and legal and regulatory issues.
DeVry also offers a bachelor’s degree in technical management with a specialization in health information management, which allows students who earn their associate’s at DeVry to continue their studies seamlessly.
The 67-credit program includes courses such as basic medical terminology, introduction to health services and information systems, international classification of diseases coding, current procedural terminology coding, legal and regulatory issues in health information, health insurance and reimbursement, and psychopharmacology.
- Location: Online
- Accreditation: Higher Learning Commission (HLC; Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
- Expected Time to Completion: 16 months
Weber State University’s online associate of applied science degree in health information technology (HIT) prepares students to succeed in this growing field of information management and healthcare coding. This AAS program is an excellent stepping stone between a certificate in healthcare coding and a health information management bachelor’s degree. Based on the 2020-2021 academic year, 100% of Weber State University’s HIT program graduates passed the RHIT certification examination on their first attempt.
The curriculum of this program includes courses such as healthcare privacy and security, diagnosis coding, ambulatory and physician office coding, ICD-10-PCS coding, healthcare database management and security, computer applications in healthcare, and an introduction to quality improvement in healthcare.
Graduates of this program will be ready to work in various healthcare settings such as medical clinics and hospitals, insurance companies, home health agencies, mental health facilities, skilled nursing facilities, software vendors, public health agencies, and health maintenance organizations.
- Location: Ogden, UT
- Accreditation: Northwest Commission on Colleges and Universities (NWCCU); Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
- Expected Time to Completion: Two years
How Long Does it Take to Become a Clinical Documentation Specialist?
The road to becoming a documentation improvement specialist varies. Expect at least one year to attain a postsecondary award in a clinical documentation specialization. Set aside enough time to complete programs, up to three years, as some are on predetermined schedules and others are completed at the student’s pace.
Students pursuing a bachelor’s degree in health information technology or a related field might need up to five years to complete, including certification.
How To Become a Clinical Documentation Specialist – Step-by-Step Guide
As mentioned above, becoming a clinical documentation specialist should take students a minimum of one year and up to five years after high school, depending on the educational path chosen, certifications needed, and clinical and industry experience required.
Step 1: Graduate From High School (Four Years)
Focusing on classes in English and language arts, algebra, chemistry, physics, psychology, biology, geometry, speech, and anatomy/physiology as a high school student can help build a solid foundation for pursuing a certification in clinical documentation improvement.
Step 2: Earn a Postsecondary Nondegree Award or Certification (One Year or More)
Earn certification or postsecondary nondegree award in clinical documentation (CDI) or as a documentation improvement practitioner (CDIP) to qualify yourself as a professional in the field. AHIMA’s aforementioned CDI certification is a great place to begin.
Step 3: Gain Industry Experience (At Least One Year)
One way to advance a career as a clinical documentation specialist is to gain work experience in the health and medical records industry. This helps a candidate prepare for more advanced certifications and gain the experience necessary for more leadership responsibilities, which are typically requisite in candidates being considered for positions in upper management or clinical directors.
Step 4: Earn an Associate or Bachelor’s Degree (Optional, One to Four Years)
Earning an associate of science or arts (AS, AS, AAS) or a bachelor of science or arts (BS, BA) in health information management or health information technology can increase one’s earnings and open doors to upper-level positions. However, college degrees of any kind are not necessary for those interested in a career as a clinical documentation specialist.
What Do Clinical Documentation Specialists Do?
A clinical documentation specialist, also known as a documentation improvement specialist, ensures that official healthcare recording and documentation standards are upheld. The job is closely related to medical claims billing because both fields rely on a deep, studious recall of medical codes.
Clinical documentation jobs exist at all levels of healthcare. As paperwork (or its digital equivalent) will never go away, certified clinical documentation specialists are critical to healthcare businesses so that their profiling, reimbursement, quality measure reporting, and quality control standards are consistently upheld.
Apart from these essential duties, CD specialists collaborate with other healthcare professionals to ensure that clinical information in the medical record is accurate, code the appropriate utilization, and ensure “compliant reimbursement” of any and all patient services.
Some critical skills for clinical documentation or clinical documentation improvement practitioners include:
- Working knowledge of basic computer programs
- Working knowledge of Microsoft Office Suite
- Typing
- Thorough understanding of industry coding practices (e.g., ICD-10-CM)
- Inpatient/outpatient coding skills
- Interpersonal skills
- Communications skills
- Chart review experience
- Electronic medical record (EMR) experience
- Clinical documentation specialization/improvement software experience
- Background in reporting
Clinical Documentation Specialist Certifications & Licensure
To become a clinical documentation specialist, you can become certified through either the Association of Clinical Documentation Integrity Specialists (ACDIS), which offers certifications for entry-level employees, or the clinical documentation improvement practitioner course of study through the American Health Information Management Association (AHIMA).
AHIMA offers one certification, while ACDIS hosts three: the Certified Clinical Documentation Specialist (CCDS), the Certified Clinical Documentation Specialist – Outpatient (CCDS-O), and an ACDIS-Approved CDI Apprentice Program.
The qualifications and certification procedures vary at each level of credentialing and are available on their websites.
How Much Do Clinical Documentation Specialists Make?
The Bureau of Labor Statistics (BLS 2024) reports that the clinical documentation-related field of medical records specialists is set to grow 9 percent between 2023 and 2033, adding 16,700 jobs. The BLS notes that the required entry-level education for a clinical documentation specialist is a postsecondary nondegree award.
Finally, here are the detailed salary data for the 180,570 medical records specialists in the United States, according to the BLS (May 2023):
- Average annual salary: $53,690
- 10th percentile salary: $35,080
- 25th percentile salary: $39,620
- 50th percentile (median): $48,780
- 75th percentile salary: $61,960
- 90th percentile: $77,810
Clinical Documentation Specialist Career Alternatives
Here are a few alternatives to a career as a clinical documentation specialist.
Become a Health Data Analyst
Health data analysts synthesize and analyze data gathered in healthcare facilities on everything from patient care to expenses to staffing. This information is then put into reports to help healthcare managers make data-driven decisions to improve patient outcomes, facility management, and budgeting.
- Typical Education: Bachelor’s degree
- Licensing or Certifying Organization: American Health Information Management Association (AHIMA)
Become a Medical Transcriptionist
Many healthcare providers use audio recorders to dictate their chart notes. Medical transcriptionists then transcribe these recordings into chart notes. Medical transcriptionists may transcribe the entire recording or use software for the bulk of the transcription and then spot-check for errors.
- Typical Education: Associate or bachelor’s degree
- Licensing or Certifying Organization: Association for Healthcare Documentation Integrity (AHDI)
Become a Clinical Research Coordinator
Clinical trials are complicated and require extensive oversight. One essential team member is the clinical research coordinator, who is responsible for most of the administrative tasks in a clinical trial. Duties can include ordering supplies, ensuring the integrity of the data collected, recruiting trial participants, and managing the budget.
- Typical Education: Bachelor’s degree
- Licensing or Certifying Organization: Association of Clinical Research Professionals (ACRP), Society of Clinical Research Associates (SOCRA)
Kenneth Parker
WriterKenneth is a feature writer, poet, and musician living in the Pacific Northwest. His writing on remote work, education, and technology has been published by BustedCubicle.com, MedicalTechnologySchools.com, and other websites. His poetry, short fiction, and album reviews have appeared in Scifaikuest, Nanoism, and No Clean Singing. His background includes time spent as an associate editor, proofreader, private grammar instructor, freelance content editor, medical claims agent, and SEO consultant. He is a graduate of the University of Oregon, where he studied literature and worked as a composition tutor.
Kimmy Gustafson
WriterAt HealthcareDegree.com, Kimmy Gustafson has delivered in-depth and insightful articles since 2019, aiding prospective students to navigate the complexities of choosing the right healthcare degree. Her recent work includes topics such as the ethics of gene editing and physician assistant’s fight for autonomy.
Kimmy has been a freelance writer for more than a decade, writing hundreds of articles on a wide variety of topics such as startups, nonprofits, healthcare, kiteboarding, the outdoors, and higher education. She is passionate about seeing the world and has traveled to over 27 countries. She holds a bachelor’s degree in journalism from the University of Oregon. When not working, she can be found outdoors, parenting, kiteboarding, or cooking.