How to become a certified clinical documentation specialist?

[Nurse Beth, MSN]

The Association of Clinical Documentation Integrity Specialists (ACDIS) offers the  Certified Clinical Documentation Specialist (CCDS) certification.

Becoming involves a combination of education, experience, and passing a certification exam. Here's a step-by-step guide to prepare for and obtain the training needed:

1. Educational Background

Obtain a relevant degree. A background in healthcare is essential. This could be a degree in nursing, health information management, or a related field.

Courses in medical terminology and anatomy. Understanding medical terminology, anatomy, and physiology is crucial.

2. Gain Experience

Clinical experience. Experience working in a clinical setting is highly beneficial. This could be as a nurse, physician assistant, or health information manager roles.

Documentation experience. Work in roles that involve clinical documentation, such as medical coder, health information technician, or clinical documentation improvement (CDI) specialist.

3. Additional Training and Education

CDI training programs. Enroll in specialized CDI training programs or courses offered by recognized institutions. These can be online or in-person and often cover best practices in clinical documentation.

Examples include courses from AHIMA (American Health Information Management Association) or ACDIS (Association of Clinical Documentation Integrity Specialists).

Continuing education. Regularly participate in continuing education to stay updated on the latest CDI practices and guidelines.

4. Certification Preparation

Review the exam content outline to understand the topics covered in the CCDS exam. The ACDIS website provides an exam content outline.

Study materials. Use study guides, textbooks, and online resources for CCDS exam preparation.

Practice exams. Take practice exams to familiarize yourself with the certification exam's format and types of questions.

5. Join Professional Organizations

Membership in CDI associations. Join professional organizations like ACDIS. These organizations often provide resources, networking opportunities, and professional development.

Attend conferences and workshops. Participate in conferences, workshops, and seminars to enhance your knowledge and skills.

6. Apply for the Certification Exam

Meet the eligibility requirements. The eligibility criteria typically include a combination of education and experience in CDI.

Submit your application. Complete and apply for the CCDS exam through the ACDIS website. 

7. Pass the CCDS Exam

Exam structure. The CCDS exam consists of multiple-choice questions that test your knowledge and competency in clinical documentation improvement.

Exam day prep. On the exam day, ensure you are well-rested and have all necessary identification and materials.

8. Maintain Certification

Continuing education: To maintain your certification, engage in ongoing education. The CCDS credential requires periodic renewal through continuing education credits.

Following these steps, you can prepare effectively and obtain the necessary training to become a Certified Clinical Documentation Specialist.

Best wishes,

Nurse Beth