Clinical Documentation Specialist Job Description: 5 Traits that You’ll Need to Have

Clinical Documentation Specialist (CDS) jobs are on the rise as more and more healthcare facilities and practices acknowledge (or have been told) that there are concerns regarding their patient records.

Read this brief Clinical Documentation Specialist job description to find out the qualifications and responsibilities and if this is a good job for you.

Clinical Documentation Specialist Job Description

The role of this position is to ensure full compliance with federal and state standards for healthcare documentation.

They review and analyze patient health records to identify and assess the descriptions and explanations of diagnoses, treatments, and procedures.

The CDS works collaboratively with physicians, medical coders, and other healthcare professionals to ensure that the clinical information in patients’ medical record is complete and accurate.

This individual must remain aware of changes in pertinent regulations for payment procedures, stay informed of changes in treatment modes and new procedures, and edit coding when physician documentation is vague or missing.

This position also plays a significant role in HIPAA compliance.

The Work and Responsibilities of a CDS

A Clinical Documentation Specialist wears a lot of hats, yet manages to wear them all with aplomb. In a typical day, they perform any or all of the following responsibilities:

  • Reviewing and analyzing patient health records for accuracy and appropriate detail
  • Translating diagnostic phrases from healthcare providers into medical coding
  • Interacting with healthcare providers to ensure the terms they used in the records have been translated and coded correctly
  • Assigning the appropriate DRG (diagnosis-related group, a coding term used in billing) after reviewing a medical record
  • Working with the coding team to refine their practices
  • Staying apprised of and teaching others about ongoing changes in federal and state regulations affecting healthcare (including but not limited to HIPAA)
  • Keeping informed about changes in treatment modes and new procedures
  • Gathering information on and making edits to coding when physician documentation is unclear

This is a preliminary list. We are fairly certain that a new hire would have additional items to include.

Required Credentials

This individual should be trained as an RN, or the equivalent (perhaps health services or public health, along with clinical experience).

They should be experienced in acute care and have exceptional insight and critical thinking skills, plus the ability to prioritize and analyze data quickly and accurately.

They need to have worked with patients as well as medical professionals so as to be able to understand fully the various “stories” reflected in the medical records.

The Five Most Important Traits for a CDS

These represent a distillation of all the smaller personal attributes we admire in our colleagues and others and feel would help us select the best CDS from the hiring pool.

1. Teamwork and Collaboration Skills

These are necessary abilities in a hospital or medical practice setting. Without them, and years of practice exercising them, a candidate would not succeed as a CDS.

2. Computer Proficiency

This includes standard software such as Microsoft Office. It also includes the hospital or practice’s record-management and coding software, which the new hire likely will have the responsibility of updating periodically.

3. Effective Oral and Written Communication Skills

A responsibility of this position is instructing others on new regulations, processes, and other topics. The individual hired will need to communicate this information in multiple ways.

4. Attentive Reading and Listening Skills; Meticulous Attention to Detail

This individual will be responsible for ensuring proper documentation and coding of patient records. Thus, it’s vital that they be able to understand what’s written, or should be written, in them and make corrections as needed.

5. Experience Working in Hospitals, Clinics, and/or Medical Practices

This person must be able to navigate various clinical settings. This is essential to performing the CDS job well.

Good Luck!

Now that you have read the Clinical Documentation Specialist job description, what do you think? Is this the right job for you?

If you have these qualifications, you will be a valuable employee wherever you go. We wish you the greatest success in landing a CDS position, one that is closely related, or whatever suits you best.

And as you ponder your future work, you should browse through our blog for other career ideas that might appeal to you.

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