How my nursing career took an unexpected career path into clinical documentation improvement

By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, CDI Education Director at HCPro and ACDIS

Thirty-two years ago, I proudly received my BSN from the University of Vermont. I was young and didn’t know what I didn’t know. I did know that this degree in nursing would provide me with a lifelong career. I had goals. I remember how impressive my first preceptor and unit educator were and I wanted to be just like them and teach the new graduates.

Very quickly, likely too quickly, I assumed the role of preceptor. After many years in nursing, I did become a unit educator, and then a nursing clinical instructor for a local college, and even the director of education at a large hospital. It is amazing when you set a goal that you can make it happen! In those 32 years I also took on the roles of nurse manager, compliance officer, office manager, director, and countless experiences in between. Nursing has been good to me.

But a little over a decade ago, I started down a completely unexpected path. I took a chance and took on the role of Clinical Documentation Improvement Specialist (CDIS). At first, I did not think this would be a huge change. The job description described record review and physician education related to their documentation or lack thereof. It seemed easy … just as when I first started my career, I didn’t know what I didn’t know.

While the majority of CDI specialists are nurses, nursing is only one avenue that can take you to this role. We also see experienced professionals from health information management, such as professional coders, in this role, as well as physician assistants, nurse practitioners, physicians, and other healthcare professionals.

The wide variety of experience reinforces the fact that to be successful in this position your scope of knowledge will need to expand. That is why when I began in this role I encountered the steepest learning curve of any new position I had ever taken.

But the climb was well worth it. As I have I stated above, over the years I have worked in a number of different roles, and the skills and knowledge from each one of those roles led me to the position of CDIS. That said, the rules and regulations related to coding and the process of reimbursement for inpatient acute care was quite foreign to me. I would say my first 12-18 months were a challenge. But with the challenge was also a job that I have found to be the most stimulating and fun position of any in my 32 years.

When people ask me if I ever have second guessed my decision to choose nursing as my career, I always cite my present focus and tell them that the last 32 years have been a wild ride. Every curve has prepared me for the focus I have now and I am so thankful it did. I enjoy my work every day and enjoy the many professionals I meet who call CDI their profession.