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Becoming a Clinical Documentation Specialist: Your Step By Step Guide

Jobs in the health information field are expected to grow by 11% between now and 2028. Given our aging population and increasing reliance on technology, this isn’t a surprise.

Are you looking for a stable job in the health information field? Then you should consider becoming a Clinical Documentation Specialist. In this role, you’d check patient records, communicate with physicians, and solve problems.

There are a lot of Clinical Documentation Specialist jobs out there. However, gaining the right requirements can be tough. 

If you’re a detail-oriented person who loves solving problems, this could be the job for you! Read on to learn how to get started on this career path.

Get an Education 

You can choose between a 4-year Bachelor’s or a 2-year Associate’s program. Employers hire candidates with either degree type. You might find more job opportunities with a Bachelor’s degree though.

Documentation specialists have degrees in nursing, allied health, and other disciplines. Make sure to take classes on medical terminology, human anatomy, and pharmacology. These courses will make you a better documentation specialist.

Since checking medical codes is a big part of what they do, you should take a course on medical coding.

Get Work Experience

Many documentation specialist positions require at least three years of experience. Luckily, there are several ways to get this experience.

Many Bachelor’s degree programs offer apprenticeships or practicums.

You’ll be able to learn from experienced document specialists while getting your degree. 

Nursing experience is also great preparation for this career path. You’ll learn how to gather medical histories and build professional relationships with physicians.

Another option is to get a job at the front desk of a clinic or as a records technician. You’ll learn how to problem solve, organize records, and learn medical coding.

Take the CCDS Certification Exam 

The CCDS credential proves your education and work experience. It’s optional, but it can help you earn higher-level positions. You can take the exam once you’ve finished your coursework and you have 1-2 years of work experience.

After passing the exam, you will become a Certified Clinical Documentation Specialist (CCDS). Testing is offered through ACDIS, the Association of Clinical Documentation Integrity Specialists. 

Depending on the employer, a CCDS certification may or may not be required to get a job. If it’s not required, it’s still a credential that will set you apart from other applicants.

Apply for Clinical Documentation Specialist Jobs 

The final step is to apply for Clinical Documentation Specialist jobs. 

Make sure to prepare answers to common interview questions for document specialists. Think about your skills in leadership, problem-solving, and communicating with physicians. 

Knowing how to interview and what types of characteristics potential employers are looking for is a good way to prepare.

Considering This Career?

Your degree, work experience, and CCDS certification will help you land your dream job. In this position, you’ll be in charge of record organization and solving problems with records.

Your role will make the hospital, clinic, or research center where you work operate more efficiently.

A healthy work-life balance is just as important as your career. Check out our lifestyle articles for helpful tips in your daily life! 

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