FAQContact usTerms of servicePrivacy Policy

What would an experienced RN have to do to become a documentation specialist?

Friday October 25, 2013
Printer Icon
Select Text Size: Zoom In Zoom Out
Share this Nurse.com Article
rss feed

Dear Donna,

I have been working primarily in emergency nursing for the past 33 years and I'm just tired. I have read some information about a documentation specialist position, and I know I'm very good at proofreading and documentation. What would I have to do to enter this field? I have an ADN.


Dear Donna replies:

Dear Tired,

The role/title clinical documentation improvement specialist is becoming more popular as regulatory and reimbursement issues become more complex. The specific job description may vary from hospital to hospital. Typically a CDI professional provides education and does chart audit and review to be sure that physicians and nurses properly document resource utilization to support quality, legal and reimbursement requirements and standards. CDI specialists also work with medical coders to be sure the coding is accurate and so on.

You can learn more about this specialty through The Association of Clinical Documentation Improvement Specialists (www.hcpro.com/acdis/). Do some informational interviewing (www.Nurse.com/Cardillo/Interviewing) with officers and members of the association or anyone in this position in your area. Also go to local chapter meetings as a guest. When there's something you want to do, it makes sense to rub elbows with those already doing it.

Because you are looking to transition, be sure to explore all of your options before taking any courses or moving forward. Read How to change specialties (www.Nurse.com/Cardillo/Change-Specialties). If you can, attend an upcoming Career Alternatives for Nurses seminar http (www.Nurse.com/Events/CE-seminars) to identify transferable skills, find out what specialties are hot and growing and learn how to effectively market yourself in an increasingly competitive job market.

In the meantime, take steps to go back to school for your BSN. Although not specifically required for this position, a minimum of a bachelor's degree is important in an increasingly complex healthcare environment and is required by a growing number of employers.

Best wishes,


Donna Cardillo, RN, MA, well-known career guru, is Nurse.com’s “Dear Donna” and author of “Your First Year as a Nurse: Making the Transition from Total Novice to Successful Professional” and “The ULTIMATE Career Guide for Nurses: Practical Advice for Thriving at Every Stage of Your Career.” Information about the books is available at www.Nurse.com/CE/7010 and www.Nurse.com/CE/7250, respectively. To ask Donna your question, go to www.Nurse.com/Asktheexperts/Deardonna. Find a “Dear Donna” seminar near you: Call 800-866-0919 or visit http://www. Nurse.com/Events.