CDS Job Description

The Clinical Documentation Specialist role is a dynamic and challenging one. The selection of the right individual(s) is critical to the success of your CDI program.  The successful candidate(s) must be resilient, exhibit excellent initiative and communication skills.

This job description is intended as a guide only and may be adapted as required.

Example position description

Position title: Clinical Documentation Specialist (CDS)

Position Summary: responsible for facilitating the overall quality, completeness, timeliness, and accuracy of clinical documentation in the patient record to support; the delivery of high-quality patient care, accreditation and adherence to quality standards, the clinical coding process and appropriate hospital funding.

Roles and Responsibilities:

  • Develop and co-ordinate a Clinical Documentation Improvement (CDI) program with the aim of optimising the facilities clinical documentation
  • Conduct concurrent reviews of selected patient records with the aim of identifying where there is clear evidence of investigations undertaken or administration of treatments, but no diagnosis is present
  • Engage with clinicians to help close the gaps in their clinical documentation
  • Deliver ongoing education regarding CDI to all clinical staff responsible for documenting in the patient record.

Role Requirements:

  • A Bachelor’s/Master’s degree in either Nursing, Allied Health, Medicine, Health Information Management or equivalent
  • 3 years post graduate experience (acute care desirable)
  • Demonstrated interest in quality improvement (experience of involvement in quality improvement projects desirable)
  • Previous experience in change management

Personal Competencies:

  • Evidence of strong critical thinking/problem solving and analytical skills
  • Possess significant personal initiative and be skilled in program development
  • Demonstrated high level organisational skills with attention to detail
  • Excellent communication skills and ability to engage with a variety of stakeholders
  • Ability to work autonomously and within a diverse team.

Key Performance Indicators:

  • Conduct on average 8-12 record reviews per day
  • Collect, analyse and report on performance metrics of clinical documentation improvement to the hospital executive team.


If you are currently recruiting for a CDS, why not post your job to our job board?

If you are looking for support, or would like assistance when recruiting the right CDS to your organisation, please contact us


We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community!  Contact to learn more.