What Does a Clinical Documentation Specialist Do?

Maggie Worth

A documentation specialist is someone who specializes in documenting facts, processes, procedures and results. A clinical documentation specialist is someone who completes these duties in a healthcare setting, such as a hospital or a doctor's office. Such specialists are primarily responsible for documenting the clinical details of a patient's condition, diagnoses and progress. She is most often a clinical worker, such as a nurse or physician's assistant, but could also be a non-clinical employee.

A clinical documentation specialist may work with CAT scans.
A clinical documentation specialist may work with CAT scans.

The purpose of a clinical documentation specialist is to ensure that all information pertaining to a patient is captured and written down. This helps nurses and doctors make an accurate assessment of a patient's condition, make the most appropriate recommendations for treatment and provide the best patient care. The information captured by a clinical documentation specialist forms the basis for many diagnoses and treatment plans, so it is critical that the data be documented accurately and in a timely manner.

A clinical documentation specialist works in a healthcare setting, such as a hospital or a doctor's office.
A clinical documentation specialist works in a healthcare setting, such as a hospital or a doctor's office.

The range of data captured by a clinical documentation specialist is extensive. It can include patient condition information, such as vital signs and appearance. It can also include results of tests, including blood work, CAT scans, EKGs and more. It usually includes treatment data as well, such as the name and dosage of all medications administered and the time of administration.

The purpose of a clinical documentation specialist is to ensure that all information pertaining to a patient is captured and written down.
The purpose of a clinical documentation specialist is to ensure that all information pertaining to a patient is captured and written down.

A number of healthcare entities employ clinical documentation specialists. The largest employers are hospitals, medical centers and doctor's offices. Other employers might include radiology clinics, training facilities and insurance companies.

Some nurses and physician assistants serve as clinical documentation specialists.
Some nurses and physician assistants serve as clinical documentation specialists.

Often, the documents created by a clinical documentation specialist are needed for insurance purposes. Insurance providers may want to verify that the most effective treatment is being offered to the patient or may want to ensure that post-procedure certifications were medically necessary rather than simply a delay in paperwork. These documents can mean the difference between approval and denial of an insurance claim.

On occasion, these records may also be subpoenaed in a court case. This is particularly true when a medical facility or physician is accused of malpractice. Either the defense or the prosecution may make use of the documents in such a situation.

In many areas, a person serving as a clinical documentation specialist must be a trained, licensed clinician. This means that she must also be a nurse, doctor, pharmacist or physician's assistant, or hold another such clinical healthcare role. In some locations, however, non-clinical healthcare workers can be trained as documentation specialists. This is particularly true in nations or areas experiencing severe shortages in clinical healthcare workers.

A clinical documentation specialist may be responsible for collecting information about a patient's vital signs.
A clinical documentation specialist may be responsible for collecting information about a patient's vital signs.

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