Clinical Documentation Specialist Job Description, Duties, and Responsibilities

This post presents detailed information on the clinical documentation specialist job description, including the key duties, tasks, and responsibilities they commonly perform.

It also highlights the major requirements you may be expected to meet to be hired for the clinical documentation specialist role by most employers/recruiters.

What Does a Clinical Documentation Specialist Do?

Clinical documentation specialists are responsible for improving the overall quality and completeness of clinical documentation.

The clinical documentation specialist job description entails promoting partnership between concurrent clinical reviewers, medical record coders, and physicians to improve documentation and information preservation.

They make sure clinical information to be used is accurate and complete; measure and report to physicians the hospital outcomes of patients to reflect the true severity of their illness, intensity of care required, and risk of mortality.

They educate and keep all members of the health care team informed on the issues at hand on a regular basis.

Their role also involves analyzing documentations from medical diagnosis and treatment to enable medical staff and facilities provide better health care for patients.

Documentation specialists need to understand medical terminologies, procedures, and applicable laws to collect and evaluate medical documentation.

They create written reports which they provide to medical professionals, decision makers, and the public so that healthcare efforts in a facility can be judged objectively.

Their work description also entails interpreting reports to identify positive or negative outcomes of solutions proffered for health care problems.

They act as medical record technicians who collect information and enter into databases from where they can produce reports which health providers analyze to determine problems or areas of improvement.

In larger facilities, clinical documentation specialists can take on research, administrative, and educational functions.

They train health information technicians and medical staff on documentation and standard procedures for analysis of health records.

They track statistics on disease and recovery to produce reports on the efficiency of collection methods, and also recommend strategies for improving documentation processes.

As part of their duties, documentation specialists at clinics meet with healthcare staff members to explain their findings.

To work in this career requires possessing an associate degree in health information technology or a bachelor’s degree in health services, public health, or long term care administration.

Some of the qualities you will need to succeed on the job include excellent communication skills and proficiency in computer use, organization and planning.

Clinical Documentation Specialist Job Description Example/Template

Documentation specialists working in clinics perform various functions that make their role vital in the healthcare sector.

Here is a job description example that shows the major tasks, duties, and responsibilities that clinical documentation specialists commonly perform:

• Collect information about patients’ diagnoses and upload on computer databases
• Assess patient’s medical documents to ensure accuracy
• Educate medical coders and billers on standard procedures that must be followed when composing medical documents
• Recommend strategies for improving record keeping processes
• Ensure all clinical documents are in compliance with federal laws in terms of composition and secure storage
• Apply knowledge of medical terminology and procedures to properly evaluate clinical documents
• Prepare written reports for public health officials who evaluate health care facilities
• Interpret clinical reports to identify health related issues and assist in addressing patient health problems
• Train information specialists on proper methods of documentation and maintenance of medical records
• Promote continuity on specific clinical documentation throughout the record
• Accurately report and describe the severity of patient’s illness so as to make known the action required
• Facilitate complete discharge summaries.

Requirements – Skills, Abilities, and Knowledge – for Clinical Documentation Specialist Job

Are you seeking the clinical documentation specialist job? If you are, then here are common requirements you will need to provide to most employers to be qualified to access the position:

• Education and Training: To become a clinical documentation specialist requires a bachelor’s degree in health information technology or at least an associate’s degree in applied science
• IT Skill: Clinical documentation specialists must have excellent computer skills and knowledge of software for database maintenance and electronic health record storage
• Communication Skill: They must have excellent communication skill, both written and verbal applied in the provision of accurate information to healthcare staff
• Interpersonal Skill: They should be able to relate and work with others in the clinical setting so as to create an air of understanding among all units.

Conclusion

If you are hiring for the clinical documentation specialist position in your organization, you need to publish a good description for the role to attract the best candidates.

To achieve this, the sample job description provided in this post will help you create one for your organization.

This post will also help those aspiring to become documentation specialists in clinics to learn about the career; the duties and responsibilities they may be assigned when hired for the role.