Who are Clinical Documentation Specialists?
Clinical documentation specialists understand a wide range of specialized disciplines including:
- Education in anatomy and physiology, pathophysiology, and pharmacology
- Knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System
- An ability to analyze and interpret medical record documentation and formulate appropriate physician queries
- An ability to benchmark and analyze clinical documentation program performance
The Certified Clinical Documentation Specialist (CCDS) credential provides a mark of distinction for this unique profession. Applicants who pass the certifying exam receive the designation CCDS.
The mission of the CCDS credential is to elevate the professional standing of clinical documentation specialists. The program draws from experienced clinical documentation specialists in the field to establish criteria for competency in the broad and multidisciplinary bodies of knowledge clinical documentation specialists must possess. These include knowledge of healthcare and coding regulations; anatomy, physiology, pharmacology, and pathophysiology; proficiency in medical record review; communication and physician query techniques; CMS quality programs and reportable diagnoses that impact quality metrics, and data mining and reporting functions.
Objectives of certification
The objectives of the CCDS program are to:
- Provide special recognition to those clinical documentation specialists who demonstrate mastery of an acquired body of knowledge and skills in clinical documentation improvement through successful completion of the certification process
- Promote documentation and medical records integrity by helping clinical documentation specialists define and obtain the requisite knowledge and skills necessary to fulfill their responsibilities
- Support compliance efforts by promoting a Code of Ethics for clinical documentation improvement specialists
- Assist hospitals and healthcare entities in identifying individuals with substantive knowledge, experience, and skills in clinical documentation improvement for the benefit of their organization