How Do I Become a Clinical Documentation Specialist?

A clinical documentation specialist manages patient medical histories and treatment records. An associate’s or bachelor’s degree in nursing is typically needed to become a clinical documentation specialist, although some employers may require a master’s degree. You will also need to become a registered nurse to work in this profession. In addition to these requirements, most employers want you to have some type of professional certification before beginning this career. After meeting these prerequisites, three to five years of practical work experience are usually needed before you can become a clinical documentation specialist.

A certain amount of formal education is typically needed to begin this career and degree requirements vary. Some employers will allow you to begin on-the-job training with only an associate’s degree in nursing, while others may require four years of college. A master’s degree may be needed if you will be working in some type of supervisory capacity. Typical nursing degree coursework includes subjects such as record-keeping, pharmacology, and patient care. Most of these programs require completion of a practicum to provide graduates with some relevant work experience.

In addition to formal college training, you must also obtain a registered nursing license before beginning this profession. In the United States, licensure is administered by the National Council of State Boards of Nursing (NCSBN). Candidates must possess a nursing degree from an accredited college and successfully complete a comprehensive examination known as the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Other countries have their own licensure requirements, so be sure to find out what is necessary in the country in which you plan to practice.

Although not necessarily required, professional certification from a well-known organization may significantly enhance your employment prospects. Medical record-keeping is a complex task that is subject to many governmental regulations. Professional certification assures prospective employers that your skills and knowledge are up-to-date with current standards and practices. In the United States, a widely recognized certification is issued by the American Health Information Management Association (AHIMA). Certification candidates must meet certain educational and work-experience requirements and successfully complete a comprehensive examination.

Most employers require three to five years of on-the-job training before you can become a clinical documentation specialist. This training typically begins with entry-level employment as a medical coder and gradually progresses to a specialist position. During this period, you will learn to classify various medical treatments for proper billing and record information, as well as compile medical treatment statistics and track individual patient cases. You will also be taught how to use various types of computer software to perform these tasks. Additionally, you will learn the correct procedures and policies for composing various clinical documents as well as important legal regulations governing the use of this confidential material.