Will “Clinical Documentation Specialist” be Automated?

Core Skills & Abilities

• Protect the security of medical records to ensure that confidentiality is maintained.

• Consult classification manuals to locate information about disease processes.

• Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.

• Process patient admission or discharge documents.

• Transcribe medical reports.

• Review records for completeness, accuracy, and compliance with regulations.

• Retrieve patient medical records for physicians, technicians, or other medical personnel.

• Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.

• Schedule medical appointments for patients.

• Process and prepare business or government forms.

• Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.

• Release information to persons or agencies according to regulations.

• Scan patients' health records into electronic formats.

• Post medical insurance billings.

• Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.

• Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.

• Identify, compile, abstract, and code patient data, using standard classification systems.