A clinical documentation specialist works with large hospitals and healthcare facilities to help maintain proper records-keeping, as well as provide primary healthcare providers with easy access to any documents needed for patient care. Because these clinics and hospitals generate a large number of records, notes, recommendations, and referrals, this position fills a key role in managing that information.
A clinical documentation specialist needs a strong familiarity with relevant computer programs and handling database queries. The specialist must understand patient records software and all systems used by his or her employer. The ability to process multiple sources of information simultaneously and the ability to think clearly and quickly are necessary job skills for a clinical documentation specialist. Typically, persons hired to fill this position are expected to have extensive backgrounds in the healthcare field. For many hospitals, this includes a bachelor’s degree in nursing at minimum, with all valid certifications and licensing required of a nursing position. Hospitals will also typically prefer persons who have done active clinical work with patients and doctors, and thus understand the requirements those personnel have for clinical documentation.
A clinical documentation specialist normally works in a hospital or medical facility; in many facilities, the records area is its own separate area of the building. These individuals may work a variety of shifts, and some large facilities require a documentation specialist available at all times.
Clinical Documentation Specialist Tasks
- Work with clinical staff to obtain information for patient records.
- Ensure that all patient documents and records are maintained in accordance with legal guidelines.
- Review accuracy, quality and completeness of clinical records.