Clinical documentation specialists possess knowledge of a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology; knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; an ability to analyze and interpret medical record documentation and formulate appropriate physician queries; and an ability to benchmark and analyze clinical documentation program performance.

The Certified Clinical Documentation Specialist credential has been created to provide a mark of distinction for this unique profession. Applicants who pass the certifying exam receive the designation CCDS.

Mission statement

The mission of the Certified Clinical Documentation Specialist credentialing program is to identify, recognize, and support a high level of experience, proficiency, and know-how among clinical documentation specialists. The program accomplishes this mission by drawing upon a board of experienced clinical documentation specialists hailing from diverse, multidisciplinary fields, including nursing, HIM/coding, quality, and case management. The board has established eligibility requirements to ensure that only experienced professionals with an ability to perform the functions of a clinical documentation specialist may possess this certification.

Objectives of certification

The objectives of the Certified Clinical Documentation Specialist program are to:

1. Provide special recognition to those clinical documentation specialists who demonstrate mastery of an acquired body of knowledge and skills in clinical documentation improvement through successful completion of the certification process
2. Promote documentation and medical records integrity by helping clinical documentation specialists define and obtain the requisite knowledge and skills necessary to fulfill their responsibilities
3. Support compliance efforts by promoting a Code of Ethics for clinical documentation improvement specialists
4. Assist hospitals and healthcare entities in identifying individuals with substantive knowledge, experience, and skills in clinical documentation improvement for the benefit of their organization

To learn more about becoming a Certified Clinical Documentation Specialist (CCDS), please browse the information on this Web site and download the Candidate Handbook.