At a recent conference, I was exposed to several thought-provoking conversations about who should ‘own’ clinical documentation improvement (CDI). Who makes the best Clinical Documentation Specialist (CDS)? Who should drive CDI programs and take ownership of CDI within hospitals?I heard people passionately defending their professions, expressing concerns that new CDSs, especially those with clinical backgrounds, could overshadow or threaten established roles, because CDI should be owned by coders and HIMs.
But here’s the truth: CDI is not about who, it’s about the why.
It’s time that we refocus on the why, and address how we can achieve success through collaboration, shared goals, and strategic implementation.
At its core, CDI exists to achieve three critical outcomes:
- Improving Patient Safety
Poor documentation can result in miscommunication, adverse events, and compromised patient care. Clear, accurate, and complete documentation ensures that every clinician involved in a patient's care is informed and aligned, enabling caregivers to effectively communicate care plans to their patients.
- Enhancing Data Integrity
Coded data informs critical decisions, including hospital business planning, clinical performance evaluations, resource allocation, and public health research. Without accurate documentation, the data becomes unreliable, impacting far more than funding—it affects trust in healthcare outcomes.
- Ensuring Financial Sustainability
In an era of increasing financial pressures, hospitals must ensure that the complexity of care is adequately documented to secure appropriate funding. Good documentation reflects the true acuity and resource intensity of patient care, supporting hospital viability and capacity to invest in better care.
CDI is not - and should never be - about competition. It’s not about whether health information managers (HIMs), clinical coders, or clinical staff are best suited to be a CDS and drive the program. Success hinges on collaboration between all stakeholders. Silos and territorial mindsets undermine what should be a shared organisational commitment.
And let's not forget it is the patient who is at the centre. We are called to work in healthcare because we want to make a meaningful impact on patients' lives. A shared vision and purpose not only influences the care of current patients but also shapes the future of healthcare by enabling better funding, improved data quality, and enhanced service delivery.
When all stakeholders including HIMs, coders, clinicians, finance teams, and quality professionals come together with a shared focus on the why, they can create a culture of continuous improvement. Collaborative practices such as joint education sessions, regular team meetings, and shared goals ensure that CDI becomes an organisational movement—not just an individual responsibility.
What Makes an Outstanding Clinical Documentation Specialist?
A good CDS, regardless of their background, must possess the following attributes to set themselves up for success:
- Clinical Knowledge and Acumen
A strong understanding of clinical care is vital. Beyond simply recognising individual diagnoses or treatments, a CDS must possess the ability to identify and interpret the intricate ways in which medical conditions coexist and interact within a patient's overall health profile.
For example, a CDS must understand how chronic conditions like diabetes or hypertension influence acute presentations such as infections or heart failure, and how these relationships impact clinical decision-making and patient outcomes. They should be able to recognise when documentation is missing critical details about these interconnections, such as complications, causal relationships, or secondary diagnoses that may significantly affect coding, data accuracy, and ultimately, patient care.
This level of clinical acumen also enables CDSs to engage in meaningful, peer-to-peer conversations with clinicians. When discussing documentation gaps, a CDS who can articulate how comorbid conditions influence each other—and how documenting them accurately reflects the true complexity of the care provided—is far more likely to gain a clinician's trust and cooperation.
- Analytical Skills
A CDS must act as a detective, performing concurrent reviews to identify inconsistencies or gaps in clinical documentation while the patient is still in hospital. To do this effectively, a CDS requires a foundational understanding of the DRG classifications - but not to the extent of knowing every intricacy. A good CDS doesn’t need to memorise the ECCS scores of every DRG or the DCL values of every condition within them. Instead, they need a working knowledge of key coding principles and standards that align with their role, such as identifying when a diagnosis is under-documented or when clinical indicators suggest a condition that hasn’t been explicitly documented.
This detective-like approach doesn’t rely on encyclopaedic coding knowledge but on the ability to think critically, apply coding basics, and work collaboratively with clinical coders.
- Relationship-Building Skills
Much of the success of CDI hinges on relationship-building. A CDS must build and maintain trust with clinicians, often by balancing education with diplomacy. Strong relationships are grounded in emotional intelligence. A CDS must be attuned to the pressures clinicians face daily - tight schedules, patient care and administrative demands, and sometimes burnout. Approaching clinicians with empathy and an understanding of their challenges fosters goodwill and reduces resistance to CDI efforts. By acknowledging these realities, the CDS can frame documentation improvement not as a critique but as a partnership to enhance patient care, streamline workflows, and support the clinicians themselves.
- Resilience
Changing entrenched behaviours is challenging. CDSs often face resistance from time-poor clinicians who may perceive documentation queries as criticisms. A resilient CDS understands that resistance is rarely personal.
Resilience empowers CDSs to persevere in the face of setbacks. Not every interaction will yield immediate results - some clinicians may dismiss queries, be slow to respond, or be flat-out rude. A resilient CDS doesn’t let these moments define their efforts. Instead, they regroup, reframe their approach, and look for opportunities to re-engage.
Strengths of CDSs from Clinical and HIM Backgrounds
CDSs can come from varied professional backgrounds, each bringing unique strengths:
- Clinical Professionals
Clinical CDSs often have a deeper understanding of medical care and terminology enabling them to communicate effectively with clinicians. Their existing relationships with clinical staff can be leveraged to foster meaningful engagement and trust.
- HIM Professionals and Coders
HIMs and coders excel in analytical thinking, with an exceptional understanding of coding standards and classifications. Their expertise ensures that documentation improvements directly translate to data quality and financial outcomes.
While neither background guarantees a perfect CDS, the best candidates embody the attributes outlined above, regardless of their origin. This reinforces the importance of identifying individuals with the right skill set, rather than a certain professional background.
Regardless of who fills the CDS roles, successful CDI programs depend on a clear and intentional strategy that includes formal onboarding and training, coaching and development, and collaborative reporting lines and relationships.
Shifting the Mindset: Collaboration Aligned with the Why
Hospitals that excel in CDI prioritise a collaborative culture. They establish clear expectations, ensure CDI programs align with organisational goals, and foster strong relationships across teams. These organisations focus on:
- Defining clear reporting lines and scope for CDSs.
- Encouraging physical and functional proximity between CDI and HIM teams.
- Scheduling regular touchpoints for collaboration and mutual learning.
- Maintaining alignment with patient safety, data integrity, and financial sustainability goals.
CDI is not about ownership. It’s about creating a culture where every stakeholder - CDSs, HIMs, coders, clinicians, and beyond - works together to achieve the same goal: improving patient safety, enhancing data integrity, and securing financial sustainability.
So let’s not focus on who.
By focusing on the why and fostering collaboration, we can ensure that CDI programs deliver meaningful, sustainable results. Together, let’s commit to a shared purpose and work toward a stronger, safer, and more effective healthcare system.