What is Clinical Documentation?
Clinical documentation is a record specifying an instance of administered clinical therapy, clinical care, or a clinical test. Clinical reports should be exact, opportune, and reflect all instructions and advisements given to a patient.
How is Clinical Documentation used?
Zippia reviewed thousands of resumes to understand how clinical documentation is used in different jobs. Explore the list of common job responsibilities related to clinical documentation below:
- Stay current with and provide ongoing clinical documentation improvement education for physicians, nursing and allied health professionals.
- Completed corporate and departmental training, and subsequently received specialty certification for clinical documentation management.
- Utilized as consultant to other Cathedral hospitals to improve their Clinical Documentation programs.
- Queried physicians for clarification on clinical documentation to positively affect CMI
- Improved clinical performance and bridge the gap between clinical documentation and regulatory requirements (Medicare and Medicaid).
- Have trained three RNs in use of laptop computers and software used in Clinical Documentation review.
Are Clinical Documentation skills in demand?
Yes, clinical documentation skills are in demand today. Currently, 10,597 job openings list clinical documentation skills as a requirement. The job descriptions that most frequently include clinical documentation skills are document management specialist, document specialist, and icd-9 coder.
How hard is it to learn Clinical Documentation?
Based on the average complexity level of the jobs that use clinical documentation the most: document management specialist, document specialist, and icd-9 coder. The complexity level of these jobs is intermediate.
On this page
What jobs can you get with Clinical Documentation skills?
You can get a job as a document management specialist, document specialist, and icd-9 coder with clinical documentation skills. After analyzing resumes and job postings, we identified these as the most common job titles for candidates with clinical documentation skills.
Document Management Specialist
Job description:
A document management specialist is in charge of managing the documents in a company using electronic systems. They typically perform research to identify the strengths or weaknesses of current processes, develop management plans and strategies to enhance procedures, implement solutions against problem areas, liaise with external parties, and coordinate with various departments to gather and analyze data. Moreover, a document management specialist must lead and encourage staff to reach goals while implementing the company's documentation management policies and regulations, creating new ones as needed.
- Clinical Documentation
- Patients
- SharePoint
- PowerPoint
- Windows
- Revision Control
Document Specialist
Job description:
Documentation specialists are responsible for managing office documents and developing a long-term storage strategy. They have varied responsibilities, including organizing, storing and retrieving records, and training other staff members on practical documentation usage. It is also their job to proofread and remove obsolete documents, utilizing storage applications and software. There are several requirements needed to be qualified for this position, including a communications degree, excellent organizational and interpersonal skills, and excellent verbal and written communication.
- Clinical Documentation
- Patients
- Customer Service
- Data Entry
- DRG
- PowerPoint
Informatics Nurse
- Clinical Practice
- Clinical Applications
- BLS
- Patient Safety
- Clinical Documentation
- Go-Live
Cerner Consultant
- Workflow Issues
- Medication Reconciliation
- Med-Surg
- Cerner Powerchart
- Clinical Documentation
- Order Entry
Clinical Applications Analyst
Job description:
Clinical application analysts are in charge of assessing software vendors, trying out various software systems, choosing an appropriate software system for an organization, and assisting with the execution of the software. Generally, they work in a clinical environment and report to managers or directors. Also, they present troubleshooting, maintenance, and improvement of existing software applications. Additionally, they work with vendors and business owners to gauge and recommend solutions to complex issues and requests, troubleshoot problems, respond to questions from end-users as well, like build, design, and install the applications.
- Project Management
- Patient Care
- Clinical Applications
- Clinical Documentation
- EHR
- Troubleshoot
How much can you earn with Clinical Documentation skills?
You can earn up to $71,208 a year with clinical documentation skills if you become a document management specialist, the highest-paying job that requires clinical documentation skills. Document specialists can earn the second-highest salary among jobs that use Python, $39,044 a year.
| Job title | Average salary | Hourly rate |
|---|---|---|
| Document Management Specialist | $71,208 | $34 |
| Document Specialist | $39,044 | $19 |
| Icd-9 Coder | $52,080 | $25 |
| Informatics Nurse | $99,161 | $48 |
| Cerner Consultant | $84,665 | $41 |
Companies using Clinical Documentation in 2026
The top companies that look for employees with clinical documentation skills are Walgreens, All Medical Personnel, and Guidehouse. In the millions of job postings we reviewed, these companies mention clinical documentation skills most frequently.
| Rank | Company | % of all skills | Job openings |
|---|---|---|---|
| 1 | Walgreens | 27% | 20,684 |
| 2 | All Medical Personnel | 12% | 151 |
| 3 | Guidehouse | 11% | 3,562 |
| 4 | Humana | 11% | 12,326 |
| 5 | Pwc | 4% | 17,170 |
Departments using Clinical Documentation
| Department | Average salary |
|---|---|
| IT | $78,847 |
| Administrative | $38,464 |
1 courses for Clinical Documentation skills
1. Essential Documentation within Clinical Research
This comprehensive course for Essential Documents will give you all the required information you need regarding documentation required for the conduct of a clinical trial. This course will cover•Define Essential Documents and their purpose •Understand what ICH GCP E6 R2 says about Essential Documents•Investigate eTMF systems and their place in accurate storage and retrieval of Essential Documents•Understand how to archive Essential Documents according to ICH GCP standards...