Have you ever wondered what a medical documentation specialist does? Or maybe you were looking for clinical jobs and came across this name but didn’t know what this job is about? Here you will learn everything about medical documentation specilist’s work.
What is a documentation specialist?
In order to understand the role of a medical documentation specialist it is important to comprehend the role of documentation specialist in general.
Documentation specialists organize documents, sort and label them as well as keep the documents up to date with legal requirements. They are also responsible for retrieving documents on demand, and preparing a sorting strategy.
What is the role of a medical documentation specialist?
Medical documentation specialists play a crucial role. Their role is to record patients’ encounters with doctors as well as to keep track of patients' medical records. The former is especially important, as the transcriptions of patients’ visits in a clinic become a part of their medical records. Medical documentation specialists can perform this task in the doctor’s cabinet, as well as remotely using, for instance, digital recordings made by the physician.
Apart from keeping track of the patients’ visits, medical documentation specialists need to ensure that the medical documentation follows the regulations, such as HIPAA requirements. In the rapidly changing environment of healthcare, this particular role is extremely important.
Another task on the list of clinical documentation specialists is to keep sure that the patients’ records are up to date. In order to provide the best-quality medical services, the doctors need to have the latest data about their patients. This means that even if medical documentation specialists do not have direct contact with the patients, their work adds to providing them with proper treatment.
What does an average day of medical documentation specialist look like?
A typical day in this role may consist of several different tasks. Medical documentation specialist perform such tasks as:
- Checking and updating patient records
- Finding missing information in the records
- Contacting doctors to fill in the missing information
- Completing the missing information in the records
- Making contact with patients’ insurance companies if required by the situation
Their work is usually 9-5, so you don’t have to worry about the shift work disorder!
What do I need to become a medical documentation specialist?
As the role of documentation specialists is of extreme importance, there are several requirements that you need to comply with in order to start working as one. The requirements may vary from offer to offer, but here are the most common ones:
- A degree in health information technology (though sometimes a high school diploma is enough)
- A good grasp of medical terminology
- RN license
- Experience in a similar role
- Knowledge of the HIPAA regulations
- High computer proficiency
- EMR software skills
If you match all these points but don’t have any experience, don’t worry! You can start your career by working in a similar position, such as a medical scribe. If you want to begin your journey in an experienced, professional healthcare company with a lot of opportunities, check our open positions for medical scribes.
The takeaway
Medical documentation specialists play an important role in medical facilities, and perform several roles connected with the medical records and medical documents. However, to do this efficiently, they need experience and a good knowledge of medical terms.
