Professional app page template for Clinical documentation specialists in Wisconsin

What is a Clinical Documentation Specialist? A clinical documentation specialist (CDS) reviews a patientʼs medical records to ensure documentation is accurate as well as up-to-date with the latest information on a patientʼs illness. They also record the details of every step-in clinical treatment.

Clinical document specialists are responsible for managing a medical facilityʼs paperwork. Individuals who work in this role organize important medical documents for health care specialists, doctors, nurses and other medical staff.

A Documentation Specialist is an administrative professional who is responsible for maintenance of company documents. Their job is to store, catalogue and retrieve documents. This may involve maintaining paper files, electronic files, or even databases.

The basics of clinical documentation Date, time and sign every entry. Write your name and role as a heading and the names and roles of all others present at the encounter. Make entries immediately or as soon as possible after care is given. Be legible. Be thorough, accurate, and objective. Maintain a professional tone.

In analyzing what skills a clinical documentation improvement specialist should have in order to be successful in the role, Zippia found the following skills most commonly on clinical documentation improvement specialistsʼ resumes: Patient Skills: 18.1% Patient Care: 13.5% Clinical Documentation Improvement: 12.4%

Put simply, a clinical documentation specialist has to make sure all the information gathered and recorded about a patient is accurate and detailed. They may go through every piece of paper and every line of medical code for each patientʼs case.

An average day in the life of a clinical documentation specialist may look something like this: Evaluating a certain number of patient records. Going through records for specificity and proper documentation. Inputting document queries into a system for doctors, specialists, and other personnel.

A clinical documentation specialist, also called a medical coder or billing specialist, oversees all types of health care documents. As a clinical documentation specialist, your responsibilities and duties include checking patient records are accurate and complete and entering data into the electronic records system.