How to Begin Training for Clinical Documentation Specialist?

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How to Begin Training for Clinical Documentation Specialist?

Hello Nurse Beth,

I am an RN in the state of Tennessee. I am trying to find out how to begin training to become a Clinical Documentation Specialist. NOBODY I have spoken with has been able to direct me on where and what to do to begin training. I have been told that to get certified as a Clinical Documentation Specialist, you must work 2 years in clinical documentation to become eligible to take the certification exam.

However, NOBODY has been able to direct me on what I need to do to begin training. I have spoke with a few colleges. They offer degrees in Health Information Management where you will receive an associates or bachelors degree. But from some of the research I have done, I'm not sure that I need to have either of the above to be a clinical documentation specialist. I have my associates in nursing. I just simply can't get any concrete answers about this. If you have any information about this, or know someone that does, please let me know. Thank you in advance!

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Specializes in Tele, ICU, Staff Development.

Dear How to Begin,

Try the  ACDIS CDI Apprenticeship.  It's an apprenticeship program that results in a certificate attesting to foundational knowledge, not to be confused with certification. (As you said, eligibility for certification requires 2 years of working in the field.)

In the program, you will learn coding guidelines and documentation criteria for sepsis, heart failure, acute respiratory failure and more. This ensures that organizations realize maximum reimbursement. 

After successful completion of the apprenticeship course and the culminating exam, you can use the designation "ACDIS-Approved CDI Apprentice" in your resume, making you more competitive for a job in Clinical Documentation.

On the job, you will have to communicate with providers and get them to clarify their documentation so the organization can bill correctly. You make sure that the documentation reflects the patient's acuity, and correct treatment.

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