Many Clinical Documentation Specialists reach a point - often three or more years into the role - where the work begins to feel repetitive. The fundamentals are well understood, confidence is established, and productivity is consistent. Yet the challenge that once drove learning and professional growth can gradually fade.
This sense of routine doesn’t mean CDI has lost its relevance or impact. More often, it signals that it’s time to intentionally re-engage with the role and seek new ways to grow within it.
Below are practical, actionable strategies CDSs can use to combat routine and bring renewed energy and purpose to their day-to-day work:
Vary Your Case Mix
Reviewing the same diagnoses, DRGs, or service lines can quickly lead to stagnation. Where possible, seek exposure to different specialties or more complex cases. Rotating case mix strengthens clinical reasoning and encourages broader thinking, making chart review less mechanical and more clinically meaningful.
Shift the Focus from Volume to Quality
Routine often develops when success is measured by output alone. Reframing focus towards the quality of documentation and queries can change how the work feels. Consider whether your queries are clinically clear, appropriately structured, and supportive of accurate clinical communication and audit readiness. Quality-driven work fosters professional satisfaction and long-term impact.
Deepen Clinical Knowledge
Strong CDI practice relies on clinical understanding, not just classification rules. Revisiting pathophysiology, reviewing current clinical practice guidelines, and aligning documentation with evidence-based care standards can reinvigorate curiosity and strengthen the clinical foundation of CDI practice.
Refresh Query Practice
Query fatigue affects both CDSs and clinicians. Reviewing and refining query templates, trialling different query formats, and reflecting on clinician response patterns can improve engagement. Thoughtful, well-framed queries enhance collaboration and elevate the perceived value of CDI input.
Take Ownership of a Documentation Opportunity
Identifying a recurring documentation gap and taking responsibility for improving it can add purpose beyond routine chart review. This may involve developing targeted education, tracking trends over time, or collaborating with coding, quality, or clinical teams. Ownership creates visibility, influence, and professional growth.
Build Skills Beyond Core CDI Tasks
Long-term engagement often comes from expanding capability. Exploring areas such as audit and compliance, health funding and classification systems (ICD-10-AM/ACHI), data interpretation, or education and presentation skills can broaden career pathways while strengthening your current role.
Step into Systems-Level Thinking
As CDSs move beyond individual chart review, there is an opportunity to shift perspective from single patient episodes to system-wide patterns within the Australian health system. Mastery of clinical documentation places experienced CDSs in a unique position to identify recurring documentation gaps, unwarranted variation in practice, and downstream impacts on quality, safety, and activity-based funding (ABF). Adopting a systems lens enables CDSs to contribute meaningfully to clinical governance, service improvement initiatives, and organisational performance discussions.
Building the Evidence Base: Research and Professional Contribution
Engaging in research, audit, and evaluation is a natural next step for experienced CDSs. Through quality improvement projects, clinical audits, and analysis of case mix and documentation data, CDSs can generate evidence that highlights the value of accurate, clinically meaningful documentation. Sharing these findings - whether through publication in the Health Information Management Journal (HIMJ), professional practice articles in HIM‑Interchange, presentations at CDIA or HIMAA conferences, or contributions to the CDIA Community page - helps strengthen the Australian CDI evidence base. This work not only positions CDSs as contributors to professional knowledge and leadership but also supports the growth and advancement of the CDS profession nationwide.
Routine in CDI isn’t a sign that the role has lost its value - it’s often a sign that mastery has been achieved. The real question then becomes: what’s next? Growth in CDI is rarely accidental; it’s intentional. Across the CDIA community, many experienced CDSs have faced this same plateau and found different ways to move beyond it. What has helped you re-engage with your role? What changes reignited your curiosity or challenged your thinking? We invite you to share your experiences and ideas - because progression in CDI is stronger when it’s shared.