Clinical Documentation Specialist Overview

Required Education and Training To Become a Clinical Documentation Specialist

Best Schools to become a Clinical Documentation Specialist in U.S. 2024

Ultimate Medical Academy

Clearwater, FL

In-State Tuition:$N/A
Out-of-State Tuition:$N/A
Admission Rate:N/A
Graduation Rate:50%
Total Enrollment:6,368

DeVry University-Illinois

Naperville, IL

In-State Tuition:$14,392
Out-of-State Tuition:$14,392
Admission Rate:43%
Graduation Rate:43%
Total Enrollment:26,384

University of Phoenix-Arizona

Phoenix, AZ

In-State Tuition:$9,552
Out-of-State Tuition:$9,552
Admission Rate:N/A
Graduation Rate:18%
Total Enrollment:88,891

NUC University

Bayamon, PR

In-State Tuition:$6,448
Out-of-State Tuition:$8,160
Admission Rate:N/A
Graduation Rate:63%
Total Enrollment:26,720

Carrington College-Sacramento

Sacramento, CA

In-State Tuition:$N/A
Out-of-State Tuition:$N/A
Admission Rate:N/A
Graduation Rate:46%
Total Enrollment:1,837

Ross College-Sylvania

Sylvania, OH

In-State Tuition:$N/A
Out-of-State Tuition:$N/A
Admission Rate:N/A
Graduation Rate:33%
Total Enrollment:894
Clinical Documentation Specialist Job Description:
  • Transcribe medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries.
  • Transcribe dictated reports and translate abbreviations into fully understandable form.
  • Edit as necessary and return reports in either printed or electronic form for review and signature, or correction.

Required Skills and Competencies To Become a Clinical Documentation Specialist

Job Duties for Clinical Documentation Specialists

  • Identify mistakes in reports and check with doctors to obtain the correct information.

  • Produce medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.

  • Return dictated reports in printed or electronic form for physician's review, signature, and corrections and for inclusion in patients' medical records.

Technologies and Skills Used by Clinical Documentation Specialists

Medical software

  • Healthcare common procedure coding system HCPCS
  • eClinicalWorks EHR software

Video creation and editing software

  • YouTube

Word processing software

  • Boston Bar Systems Corporation Sonnet
  • Microsoft Word

Basic Skills

  • Listening to others, not interrupting, and asking good questions
  • Reading work related information

Problem Solving

  • Noticing a problem and figuring out the best way to solve it

Current Job Market and Opportunites for a Clinical Documentation Specialist

Additional Resources To Help You Become a Clinical Documentation Specialist

FAQs About Becoming a Clinical Documentation Specialist