What is a Clinical Documentation Improvement Specialist?

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CanScribe is proud to announce our newest course offering: Clinical Documentation Improvement Specialist (CDIS).

This new program provides focused training in the principles of clinical documentation improvement. These principles include quality measures, payment methodologies, documentation requirements, and clinical conditions. These conditions include anatomy, physiology, pathophysiology, evaluative procedures, and interventive treatment. Code selection and query opportunities for disease processes and disorders are covered in detail, encompassing specificities.

Quality training will be the key to your success as a Clinical Documentation Improvement Specialist. CanScribe graduates are preferred throughout the industry so you can expect a quality program.

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What exactly is a Clinical Documentation Improvement Specialist? We’ve broken it down for you below.

What does a Clinical Documentation Improvement Specialist do?

A Certified Clinical Documentation Improvement (CDI) Specialist performs detailed chart analysis to identify areas within clinical documentation that need further review or improvement. CDI Specialists’ other responsibilities include:

Acting as liaisons and collaborating with coding teams and physicians to ensure that clinical documentation translates into coded data accurately.
Educate by building training resources and tools to support the coding and clinical teams.
Help medical staff better care for their patients by handling and optimizing patient records.
CDI Specialists prepare written reports, discover positive and negative patterns in documentation processes using metrics, and make suggestions for improvement.

Certified Clinical Documentation Improvement (CDI) Specialists are needed to provide further quality documentation in the healthcare industry.

What type of training do you need to become a CDIS?

You will need to complete the entire one-hundred-hour program offered by us, and it will teach you unmatched knowledge in medical language, coding, and documentation integrity. Separated into twenty-one different modules the program has sections of varying lengths from 2-8 hours.

Upon completing this program, students will be eligible to take the National Certification Exam (NCE). To receive certification and the professional designation of CCDIS, students must pass the National Certification Examination (NCE).

How big is the market for this job?

This program is relatively new in Canada and was created to streamline patients’ resources, impacting areas like documentation, data, and funding.

There is a growing need for Clinical Documentation Improvement Specialists. They have a very specialized skill set critical for the healthcare industry. The skills CDISs gain help provide accurate and quality reporting, which is essential to the industry.

As this is a relatively new position in Canada, the demand for this job is high. Accurate communication and recording of medical documentation are more important than ever in Canada.

Career Options

There are plenty of career options out there for the Clinical Documentation Improvement Specialist. With the proper training, you could be working in a medical billing center, a psychiatric office, a dental office, an insurance company, a research facility, or other healthcare-related industries. These industries will bring you up to speed on their specific role requirements.

I’m a Medical Transcriptionist. Is this course necessary to get into the field?

Medical Transcriptionists and Clinical Documentation Improvement Specialists require different training. Although some information may cross over between the two disciplines, they each have separate skillsets. While both fields help to maintain quality healthcare records, CDISs learn inpatient/outpatient coding skills, chart review skills, and learn electronic medical record skills.

Becoming a Clinical Documentation Improvement Specialist requires accuracy and a specific set of skills, just like becoming a Medical Transcriptionist. If you’re looking to get into the CDIS field, you’ll need the appropriate training.

Why should you become a CDIS?

Clinical Documentation Improvement Specialists use professional coding systems to report patient records, diagnoses, quality of care, and other services. They are responsible for the accurate documentation and recording of medical information and the quality of the health record. The role is becoming more and more critical as Canada moves towards a future with higher-quality recorded medical records.