By Fran Jurcak, MSN, RN, CCDS
The CDI specialist role is complex and multidisciplinary, suitable for clinically knowledgeable professionals who are proficient in analyzing and interpreting medical record documentation and capable of tracking and trending their CDI program goals and objectives. These professionals possess knowledge of healthcare and coding regulations, anatomy, physiology, pharmacology, and pathophysiology. Furthermore, such professionals possess the valuable ability to engage physicians in dialogue and educational efforts regarding how appropriate clinical documentation benefits patient outcomes and the overall well-being of the healthcare system.
Therefore, the CCDS exam content stems from:
- Analysis of the activities of clinical documentation specialists in a wide range of settings, hospital sizes, and circumstances
- Input from ACDIS member surveys
- Input and research of the CCDS advisory board comprised of experienced clinical documentation specialists
The examination is an objective, multiple-choice test consisting of 140 questions, 120 of which AMP uses to compute the final score. The exam questions have been designed to test the candidate’s multi-disciplinary knowledge of clinical, coding, and healthcare regulations, as well as the roles and responsibilities of a clinical documentation specialist. Choices of answers to the examination questions will be identified as A, B, C, or D and consist of the following question types:
- Recall questions test the candidate’s knowledge of specific facts and concepts relevant to the day-to-day work of CDI professionals. The examination is an open-book test; candidates may use reference resources in answering recall questions, as this is the manner in which accreditation professionals frequently carry out their responsibilities.
- Application questions require the candidate to interpret or apply information, guidelines, or rules to a particular situation.
- Analysis questions test the candidate’s ability to evaluate and integrate a range of information in problem solving to address a particular challenge.
According to the CCDS Candidate Handbook, approximately 40% of the questions can be classified as the recall type, 40% as application type, and 20% as analysis type.