Someone who specializes in documenting facts, processes, procedures, and outcomes is known as a documentation specialist. Someone who performs these tasks in a healthcare setting, such as a hospital or a doctor’s office, is known as a clinical documentation specialist. The clinical details of a patient’s condition, diagnoses, and progress are primarily documented by such specialists. She is usually a clinical worker, such as a nurse or physician’s assistant, but she can also be a non-clinical worker.
A clinical documentation specialist’s job is to make sure that all of a patient’s information is captured and written down. This enables nurses and doctors to accurately assess a patient’s condition, make the best treatment recommendations, and provide the best possible care. Because the data collected by a clinical documentation specialist is the foundation for many diagnoses and treatment plans, it’s critical that it’s documented correctly and on time.
A clinical documentation specialist can collect a wide range of information. It may include details about the patient’s health, such as vital signs and appearance. It may also include the results of tests such as blood tests, CAT scans, EKGs, and other procedures. It usually includes treatment information as well, such as the name and dosage of all medications given, as well as when they were given.
Clinical documentation specialists are employed by a number of healthcare organizations. Hospitals, medical centers, and doctor’s offices are the largest employers. Radiology clinics, training facilities, and insurance companies are all possible employers.
A clinical documentation specialist’s documents are frequently required for insurance purposes. Insurance companies may want to double-check that the patient is receiving the most effective treatment or that post-procedure certifications were medically necessary rather than just a paperwork snafu. These documents can make the difference between an insurance claim being approved or denied.
These records may be subpoenaed in a court case on occasion. When a medical facility or physician is accused of malpractice, this is especially true. In such a case, the documents could be used by either the defense or the prosecution.
Clinical documentation specialists are required to be trained and licensed clinicians in many areas. She must also be a nurse, doctor, pharmacist, or physician’s assistant, or work in another clinical healthcare position. Non-clinical healthcare workers, on the other hand, can be trained as documentation specialists in some places. This is especially true in countries or areas where clinical healthcare workers are in short supply.