A Healthcare Documentation Specialist listens to a voice recording made by doctors or other healthcare professionals and decode those information using medical transcription technology to put into an electronic record. The reports prepared by the Healthcare Documentation Specialists become part of legal medical record. That includes medical history, discharge reports, diagnosis reports, autopsy report, consultation details, referral letters and other documents. These documents hold much significance, as they are helpful in clinical decision-making, reimbursement and risk management.
1. Earn a Bachelor’s Degree: A Bachelor’s degree in medical science is must for the aspiring healthcare Documentation Specialists. The coursework may include chemistry, physics, biology, data interpretation etc.
2. Training & Skill Set: Apart from degree education, the aspiring healthcare Documentation Specialists must gain knowledge in various things including medical terms, medications, acronyms, abbreviations, medical coding, medical language, anatomy, physiology, disease processes, laboratory terminology, medical procedures, instruments, equipments, pharmacology etc.
They must take training at vocational schools, community colleges or through online education programs. The Association for Healthcare Documentation Integrity (AHDI) and the American Health Information Management Association(AHIMA) provide training in healthcare documentation and medical coding.
3. Certification: A certificate from the Registered Medical Transcriptionist (RMT), is very much necessary to give credence to the profile of Healthcare Documentation Specialists. Experience of two or more years in documentation is required as a criteria to take the exam for Certified Medical Transcriptionist (CMT) credentialing.
Salary & Job Outlook: Job outlook for Healthcare Documentation Specialists remain excellent in the United States, thanks to Obama’s push in the healthcare sector. The average annual salary of Healthcare Documentation Specialists was $32,900 in May 2010. However, at least 10% of them earned more than $46,220 per annum.