What does a medical documentation specialist do?
A healthcare documentation specialist, sometimes known as a medical transcriptionist or a medical documentation editor, listens to a voice recording made by a physician or other healthcare professional and either transcribes the information into a captured electronic record or reviews and edits a version produced by a …
How do I become a medical documentation specialist?
To become a clinical documentation specialist, you can become certified through either the Association of Clinical Documentation Integrity Specialists (ACDIS), featuring certifications for entry-level employees, or the clinical documentation improvement practitioner course of study via the American Health Information …
How much does a documentation specialist make?
Documentation Specialist Salary
| Annual Salary | Monthly Pay | |
|---|---|---|
| Top Earners | $69,500 | $5,791 |
| 75th Percentile | $54,500 | $4,541 |
| Average | $45,774 | $3,814 |
| 25th Percentile | $33,000 | $2,750 |
How do I become a CDI?
Eligibility Requirements
- Minimum of two (2) years of clinical documentation integrity experience.
- Associate’s degree or higher in a health care or allied health care discipline.
- Completion of coursework in the following topics: Medical terminology. Human anatomy and physiology. Pathology. Pharmacology.
What is meant by documentation specialist?
A Documentation Specialist is an individual responsible for the writing, distribution, collection, storage, and maintenance of a company’s documentation. In highly regulated industries, these activities are a requirement for regulatory compliance.
What is the healthcare documentation process?
Healthcare documentation is the recording of healthcare processes within the regulatory and legal requirements, typically including descriptions of patient’s past history, clinical observations, diagnostic studies, healthcare interventions, medication history, clinical course, outcome, and care-related documents.
What is a documentation specialist?
What is a certified documentation expert outpatient?
The Certified Documentation Expert Outpatient (CDEO®) credential validates expertise in reviewing outpatient documentation for accuracy to support coding, quality measures, and clinical requirements.
What is a QA documentation specialist?
A quality assurance documentation specialist reviews and verifies document records to ensure the documentation complies with regulations and internal quality control practices. As a quality assurance documentation specialist, your primary job is to maintain record archives, reviewing them for accuracy and relevance.
What’s a documentation specialist?
What Does a Documentation Specialist do? A Documentation Specialist is an individual responsible for the writing, distribution, collection, storage, and maintenance of this documentation. They can be responsible for implementing new storage systems or working to optimize the efficiency of the system already in place.
What is a CDI RN?
The Clinical Documentation Integrity (CDI) Specialist is accountable for reviewing patient medical records in the inpatient and/or outpatient setting to capture accurate representation of the severity…
What does it mean to be a healthcare documentation specialist?
A healthcare documentation specialist, sometimes known as a medical transcriptionist or a medical documentation editor, listens to a voice recording made by a physician or other healthcare professional and either transcribes the information into a captured electronic record or reviews and edits a version produced…
When do patients fill out clinical documentation forms?
Patients fill out some of these forms when they first go to a new doctor’s office, while medical professionals create others. These forms cover things like basic information and specific medical conditions that medical providers need to know. Discover a new career path today!
Can a transcriptionist discuss the content of a medical report?
Because medical records are confidential, transcriptionists cannot discuss the content of the reports they prepare; they must be careful to keep all recordings, paper and electronic files secure and prepared to follow federal guidelines for confidentiality, security and privacy.
Who is the Association for Healthcare Documentation Integrity?
The Association for Healthcare Documentation Integrity and the American Health Information Management Association oversee and approve industry training programs in healthcare documentation and medical coding. The Association for Healthcare Documentation Integrity maintains a list of approved schools.
