CCDS - Certified Clinical Documentation Specialist

The CDIA CCDS credential demonstrates that the holder has undertaken formal CDS training, time in the role of a CDS, and a comprehensive assessment process. Achieving the full credential recognises that a CDS possesses prerequisite educational requirements as well as proven, hands-on experience performing the functions of a CDS.

Course Objectives

The CDS is responsible for facilitating the overall quality, completeness, timeliness, and accuracy of clinical documentation in the patient record. This supports the delivery of highquality patient care, hospital accreditation and adherence to quality standards, the clinical coding process, and appropriate hospital funding. The role of the CDS is generally broken down into three major aspects:

  • Comprehensive review of patient medical records, whilst the patient is an inpatient, to identify gaps within the clinical documentation. This is called concurrent CDI, in contrast to the retrospective queries that coders generate. The reviews are then used to create opportunities to engage with clinicians, empowering them to improve their clinical documentation and ultimately provide safer care to every patient. The CDS acts as the bridge between clinicians and clinical coders to facilitate accurate and timely clinical coding. This enhances the integrity of the health service’s data and ensures the health service is financially sustainable.
  • Real-time conversations to positively engage with clinicians involved in the patient’s care and close the gaps in their clinical documentation. The CDS provides regular hospital-wide education to clinicians, including doctors, nurses, and allied health professionals, about complete, accurate, and specific documentation that reflects patient complexity and acuity and facilitates accurate coding. The CDS therefore must possess an advanced level of clinical acumen to positively engage with and educate clinicians.
  • Overarching development, maintenance, and growth of the hospital’s CDI program, including achieving program objectives and key performance indicators.

Course Pre-Requisites

If you wish to apply for CDIA CCDS certification, you must meet educational and/or work experience requirements.
  • Level 1 To be eligible to apply for Level 1 Certification, you must meet one of the following education or experience standards:
    • A registered nurse, health information manager, clinical coder, enrolled nurse, medical doctor, or allied health professional who has undergone formal CDS training
    • A registered nurse, health information manager, clinical coder, enrolled nurse, medical doctor, or allied health professional who has not undergone formal CDS training, but who has been in a CDS role for six months full-time equivalent.
  • If you do not meet one of these criteria, you may be considered on an individual basis based on your qualifications and work experience. You will need to email certification@cdia.com.au with your curriculum vitae and a brief description of your relevant experience.

  • Level 2 To be eligible to apply for Level 2, you must have practiced as a Level 1 CDIA CCDS for a minimum of one-year full-time equivalent.
  • Level 3 To be eligible to apply for Level 3 you must have practiced as a Level 2 CDIA CCDS for a minimum of one-year full-time equivalent.

About the CDIA CCDS CERTIFICATION

The CDS role is still in its infancy in Australian healthcare, with the earliest concurrent review programs stemming back to 2016. Since this time, CDIA has trained a large number of CDS professionals from both clinical and health information/clinical coding backgrounds. With the emergence and rapid evolution of the CDS role in Australia, the industry demand has led to the formation of the first national credentialing platform for CDSs. The CDIA CCDS certification provides the opportunity for CDSs to demonstrate a commitment to the profession whilst building their confidence and knowledge of clinical documentation improvement. The CDIA CCDS credential demonstrates that the holder has undertaken formal CDS training, time in the role of a CDS, and a comprehensive assessment process. Achieving the full credential recognises that a CDS possesses prerequisite educational requirements as well as proven, hands-on experience performing the functions of a CDS. The CDIA CDS credential has been designed to meet the needs of the CDI industry in Australia, and is applicable to a global audience, particularly applicants working in New Zealand and the Middle East, specifically Saudi Arabia. There are three levels of certification: Level 1, Level 2, and Level 3. At CDIA, we believe that providing CDSs with the opportunity for career progression is vital. CDSs continually strive for excellence, and this can be achieved through the three levels of certification. The CDIA Certification provides future employers the reassurance that a CDIA CDS is ready to hit the ground running and have an immediate impact in their organisation.

  • A Level 1 CDIA CCDS must be a registered nurse, health information manager, clinical coder, enrolled nurse, medical doctor, or allied health professional who has undergone formal CDS training OR a registered nurse, health information manager, clinical coder, enrolled nurse, medical doctor, or allied health professional who has not undergone formal CDS training, but who has been in a CDS role for a minimum of six months full-time equivalent.
  • A Level 1 CDIA CCDS will demonstrate a basic understanding of:
    • efficient, concurrent reviews of clinical documentation within a healthcare record
    • the clinical sciences underpinning clinical practice
    • critical skills such as effective communication that enable engagement and education of clinical staff
    • the fundamentals of clinical coding, the Australian Coding Standards (ACS) and casemix funding
  • Above all else, a Level 1 CDIA CCDS must demonstrate a commitment to ensuring the clinical truth is reflected in every patient record.
  • To attain Level 1 Certification, you will need to demonstrate your competence through completion of the Level 1 assessment.

  • A Level 2 CDIA CCDS is a CDS who has practiced as a CDIA CCDS Level 1 for a minimum of one year full-time equivalent and demonstrates further progression in all domains fundamental to the CDS role.
  • A Level 2 CDIA CCDS will demonstrate proficiency in more advanced aspects of the role including reporting, data analysis, effective and collaborative education, and clinician engagement. A Level 2 CDIA CCDS will demonstrate proficient application of their knowledge and skills within the clinical context in a broad range of specialties.
  • A Level 2 CDIA CCDS will exhibit progressive knowledge of clinical classification and casemix funding methodologies and how they can be applied to the role of the CDS effectively.
  • To achieve Level 2 Certification, you will need to demonstrate your competence through completion of the Level 2 assessment, including proof that you have undertaken 30 hours of CDI-related CPD and delivered 44 hours of CDI-specific education.

  • A Level 3 CDIA CCDS is a CDS who has practiced as a CDIA CCDS Level 2 for a minimum of one year full-time equivalent and demonstrates advanced experience and mastery in all domains fundamental to the CDS role.
  • The Level 3 CDIA CCDS demonstrates the ability to integrate coding and clinical information and apply them to complex patient situations. Furthermore, the Level 3 CDIA CCDS demonstrates leadership and commitment to education in the CDI field, with demonstrated impact on patient safety and quality in their workplace.
  • To achieve Level 3 Certification, you will need to demonstrate your competence through completion of the Level 3 assessment, including proof that you have undertaken 40 hours of CDI-related CPD and delivered 48 hours of CDI-specific education.

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CCDS - Certified Clinical Documentation Specialist

ABOUT CCDS COURSE

The CDIA CCDS credential demonstrates that the holder has undertaken formal CDS training, time in the role of a CDS, and a comprehensive assessment process. Achieving the full credential recognises that a CDS possesses prerequisite educational requirements as well as proven, hands-on experience performing the functions of a CDS.

The CDIA CDS credential has been designed to meet the needs of the CDI industry in Australia, and is applicable to a global audience, particularly applicants working in New Zealand and the Middle East, specifically Saudi Arabia. Know More

How And Where Is The CCDS Certification Recognised?

The CDIA CCDS certification is the only CDS certification in the ICD-10-AM/ACHI/ACS classification system globally. Whilst CDIA is not a RTO, this certification is designed to be an industry certification. Given CDIA’s status as a leader in providing CDI services, we anticipate that this certification will be recognised for all countries that use the ICD-10- AM/ACHI/ACS classifications systems. You can learn which countries this relates to via the following link: https://www.ihpa.gov.au/what-we-do/products/admitted-acute-care-products-and-licences.