Rewarding positions in the medical field have been introduced by the newest trends and revision in clinical documentation. With the implementation of clinical documentation improvement programs comes the introduction of the pivotal roles performed a clinical documentation specialist. With this type of job, you can definitely manage to live a decent life and provide for your family. Depending on the years of experience, a CDS can earn from $15 to $42 an hour. There are special cases of course when the salary actually exceeds the expectations, which is a good thing for those who are aiming to become a clinical documentation specialist.
How can a person become a clinical documentation specialist? Well just like in any other type of goal, it starts with proper motivation and determination. You have to make sure that you are really into the medical field and accept everything from the greatest rewards up to the greatest challenges. You must therefore have enough knowledge, training, awareness, education, and certification for your chosen profession. To do this, you must first earn a Bachelor’s Degree in Nursing or BSN. This is a common course that takes four years or more to complete. This is necessary since most medical institutions require someone who is well adept with the different areas in the nursing practice, clinical documentation, communication, and leadership.
After accomplishing BSN, the most logical thing to do next is to get a license or a Registered Nursing License (RN). This is one of the major qualifications for a clinical documentation specialist. The most common licensure exam would be the NCLEX-RN or the National Council Licensure Examination for Registered Nurses. Licensures are required to ensure that professionals can handle delicate tasks in the medical industry which involves services that can affect the lives of the patients.
While you may think that you’re all set to apply for the position of clinical documentation specialist, you might want to think about the competition. What is your edge over the other applicants with the same education and certification? To add up to your qualification, you can take advanced degrees such as MSN or Master’s Degree in Nursing and pass the corresponding certifications. But perhaps the most important asset that you can present is the professional clinical experience gained from any health care institution so make sure to take on-the-job trainings and other apprenticeship programs.
Sounds like a lot of work? Well, great rewards come with great responsibilities. The fruit of your hard work is what makes it rewarding anyway and to learn more, visit clinical documentation improvement forum.
Medical data is basically considered as patient centric since most of the usual information are related to diagnosis, exams, and individual reactions to medical solutions and services. But medical information extends up to the administration departments and accounts receivable aspect of the companies so it is essential for a clinical documentation specialist (CDS) to be knowledgeable on account matters. Primarily, medical data are all influenced by arranged standards along with regulations of the state. Therefore, it is also very important for the specialist to be knowledgeable on such standards over anything else.
If you believe you can fulfill the mentioned qualifications, then you’re set for an exceptional task in the medical industry. You can carry out the important role of ensuring the actual welfare of the patients while maintaining your credibility along with reputation of the medical organization. Most of all, it is possible to contribute tremendously to the total advancement of the medical field simply by preserving important information which can be used for scientific research and medical industry growth.
Medical organizations are starting to appreciate the importance of proper documentation to develop high quality medical solutions. Clinical documentation is now granted enough interest as it gets diverse in acting as the answer to varying medical requirements of the society. The tasks would certainly involve the management of massive amount of files about the patients according to the kind of clinical documentation program being utilized by the organization. As a result, medical homes and centers require the help of a clinical documentation specialist who’ll take care of the duties to make sure that clinical documentation is done successfully and effectively. The position is already extensive since those people who are in charge of coding medical info, billing and insurance accounts as well as administrative documentation are already classified under the role of a CDS.
In order to be a reliable clinical documentation specialist, it takes greater than the usual expertise in the field of medicine. The task requires an individual to have experience and knowledge on documenting medical information. This means that he or she is considered as a medical professional who understands healthcare operations and will put every little detail into file effectively. Furthermore, with the popularity of clinical documentation improvement programs, healthcare records are anticipated to be accomplished electronically with all the modern applications brought by computers and digital technology as a whole.
Consequently, there will be a dependence on a person who is trained on modern programs or applications and he should be able to adjust to modifications with minimum supervision. Furthermore, he or she will certainly lead throughout implementing parameters regarding the improvement programs. The expertise of any medical profession need to match the requirements a medical center as it will likely be determined ultimately through regularly executed audits.
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Clinical documentation specialist is a position that refers to individuals or employees who work as administrative assistant of a medical institution. This person is responsible in the documentation and safe keeping of all health related records such as the patient’s records, medical histories and other tests which will be used as a support or source for health care providers to offer the best solution and correct medical procedure for their patients. Clinical documentation specialist is also known as health information technicians.
A medical record plays a vital role in medical institution as clinical documentation serves as the foundation and resource for medical health professionals so they can provide the necessary health service needed by a patient. The mentioned documents are crucial for the overall management of the health of the patient, serve as a legal paper, used for quality reviews of the medical institution, and in order to verify the medical services offered by the physicians. It is also known that a good clinical documentation reduces the workload of both patients and the medical institution for claims processing and ensure compliance with standards in which these medical institutions are bound.
Since clinical documentation improvement has a great impact on the patient, medical providers and third parties. For the patient, it is used to verify the quality and level of necessity for medical services that a physician can offer to him or her. Maintenance or the clinical follow-up which is serves as the continuity of the patient’s medication is also described in clinical documentation. For reimbursement of the insurance claims, these documents serve as a legal basis which the patient can use in order to have get claim the benefits.
It is also through the medical records that a medical provider or a physician’s demonstration of performance such as the quality of services can be seen. In such documents, the use of Relative Value Unit or RVU and the Hierarchy Coding Category or HCC is included. For medical institutions, it is through the presence of clinical documentation where one can see the coding and billing, the medical treatment or services that were rendered to the patient and etc.
In order to have an effective and reliable clinical documentation, a medical institution needs to have an expert when it comes to the said documentation. These experts are known as the clinical documentation specialist.
With the presence of a clinical documentation specialist, the compliance of the medical institution to the regulations and the quality of clinical documentation are ensured.
To learn more, visit our CDI forum.