Clinical documentation improvement specialists impact the accuracy of medical documentation and coding in the health care system.
A strong, highly respected clinical documentation improvement (CDI) specialist program can make a difference in achieving the goals of enhancing quality care, improving case mix, and ensuring the appropriate utilization of resources through quality information.
The clinical documentation improvement specialty certification was developed with several groups of health care professionals in mind:
- Nurses and physicians with a minimum of three years of experience working in a health care setting
- Other regulated health professionals who have worked in clinical documentation improvement for a minimum of 3 years (candidates must also have completed course work in anatomy and physiology, medical terminology, and pathophysiology)
- Certified Health Information Management (CHIM) professionals who are members in good standing or international equivalent with a minimum of 3 years of current HIM work experience in coding, CDI, cancer tumour registry, and/or data analysis using ICD-10-CA and CCI data.
Note: CHIM professionals with extensive coding knowledge may find some overlap with their existing knowledge base.
Maintenance of certification
The requirements for upholding and maintaining this professional designation are as follows:
- Annual membership renewal with the Canadian Health Information Management Association (CHIMA)
- Upholding of the professional code of ethics
- Completion of the required continuing professional education (CPE) credits as per the timeframe set forth in the CPE policy
Failure to meet any of these criteria may result in decertification.
Learn about the CCDIS national certification examination
In the CCDIS NCE guide the following sections are presented:
- Section 1: About the CCDIS NCE
- Section 2: Examination application
- Section 3: Preparing for the examination
- Section 4: Writing the examination
- Section 5: Receiving results