What does a Clinical Documentation Specialist (CDS) do?

Learn about the essential daily tasks of a CDS.

You may have seen CDS roles advertised within your hospital or online, and you’re wondering what the role involves and if you’re the right person for the job.

While there is no single answer to the question of who makes the best CDS, it is common for a CDS to be an experienced nurse, health information manager or clinical coder with a nursing background. That does not mean, however, that people with other backgrounds cannot be a CDS.

Typically, the CDS role suits people who are at a point in their careers where they:

• are relatively senior yet don’t necessarily want to go into management
• want to specialise but aren’t interested in current opportunities
• are keen to do something cutting-edge and a little different to the norm
• interested in driving innovation in a new and exciting field in healthcare.

If you are thinking about becoming a CDS, it is important to consider whether you would enjoy the key daily tasks of the role to determine if you are the right fit.

The day-to-day tasks of a CDS

The CDS is responsible for implementing, developing, and monitoring a hospital’s clinical documentation improvement (CDI) program.

That means as a CDS, you will need to:

• Develop, plan, set up and lead the CDI program – ideally with the support of CDI experts, like CDIA
• Conduct lots of meetings – engage regularly with doctors, nurses, and allied health professionals to discuss their documentation and performance data
• Be able to work autonomously – plan your day and stick to your schedule without a manager closely overseeing everything that you do
• Set up and manage a steering committee – and foster this committee on an ongoing basis
• Develop and care about the ‘why’ – you will need to champion documentation and data quality and accuracy, explain how it relates to patient safety, and regularly reinforce the benefits of the program to key stakeholders.
  
  

As a CDS, you will spend your days:

• Analysing medical records – you will perform detective-like examinations of inpatient records to identify gaps in documentation
• Thinking critically about patient records – while you will not write in the patient record yourself, you need to be able to talk to clinicians about documenting a diagnosis and ensuring any treatments are clear and linked to a diagnosis
• Building relationships – you need to develop a good rapport not only with doctors, but with nurses and allied health staff
• Talking to senior clinicians – a large part of the CDS role is working with senior staff on a variety of issues
• Providing education – you will provide regular education to all clinicians to help close the gap in their clinical documentation
• Getting staff buy-in and managing setbacks – doctors may not be welcoming initially, so you need to be ready to persevere and gain their trust – resilience is an important attribute for any CDS.
   

Remember: you are still a part of the clinical team

As a CDS, you are still very much a part of the clinical team because you are engaging with clinicians daily. That means you are across what is happening with different patients and talking to doctors about the care they are delivering.

You will be encouraging clinicians to go that one step further to document why they have done something – that is, to clearly express the link between a diagnosis and a treatment.

The difference is that you don’t have a patient load and you aren’t documenting in the medical record. Documenting is outside the scope of the CDS role.

Instead, you’re helping to provide additional specificity or clarify diagnoses.

Ultimately, your role is to empower clinicians to deliver safer patient care.

You will launch a rewarding, fulfilling career pathway 

Being a CDS, you will develop exceptional skills that you will be able to use forever. You are engaging with senior executives and gaining a much broader understanding of what happens in the background of a hospital.

The best part of the job is that you have a real opportunity to improve patient care. Not only that, you will be teaching younger generations of clinical staff to understand why documentation is fundamental from a safety, quality, and communication perspective.

As well, you can ensure that the facility you are working in remains sustainable because it is getting paid for the healthcare it is delivering.

Need help choosing a CDS?

At CDIA, we can help you find the perfect person for your CDS role within your organisation – and we will support them every step of the way. Contact us today to start your CDI journey.

We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community!  Contact community@cdia.com.au to learn more.