The Role of Research in Building a Body of Knowledge for Clinical Documentation Specialists

Clinical Documentation Specialists (CDSs) play an essential role in improving the accuracy, quality, and clarity of patient records. Strong documentation not only supports patient safety and continuity of care but also influences funding, compliance, and healthcare outcomes. As the CDI profession continues to grow, the importance of research in developing a robust body of knowledge for CDS professionalisation cannot be overstated.

Research provides the evidence that validates CDI practice, demonstrates value to healthcare organisations, and shapes professional identity. Without research, the role of CDS risks being seen as purely administrative. With research, it evolves into a recognised discipline that contributes to the science of healthcare improvement.

Why Research is Essential for CDI Professionalisation

Every healthcare profession has advanced through evidence-based knowledge. Nursing, physiotherapy, and medicine all developed professional credibility through research. Clinical Documentation Specialists must follow the same path. Research in CDI is essential because it:

• Defines best practice standards in CDI by identifying what effective documentation improvement looks like and setting measurable benchmarks.

• Demonstrates the value of CDSs to healthcare executives, clinicians, and policy makers by linking documentation improvement to patient and organisational outcomes.

• Supports education and credentialing by informing training curricula, competencies, and certification pathways.

• Strengthens workforce sustainability by highlighting strategies that reduce burnout, support retention, and build long-term career pathways for CDSs.
  
  

By investing in CDI research, the profession builds credibility and ensures its place as a vital part of modern healthcare systems.

Key Research Topics to Advance the Science of CDI

Developing a body of knowledge for Clinical Documentation Improvement requires more than tracking coding accuracy or financial impact. It must also explore the organisational, behavioural, and workforce dimensions of the CDS role. Potential research topics include:

1. Impact on Patient Outcomes

• How does CDS intervention influence clinical quality indicators such as sepsis recognition or accurate reporting of comorbidities?

• Can improved documentation demonstrate measurable links to patient safety outcomes?

2. Financial and Resource Impact

• What is the relationship between CDI programs, coding accuracy, and funding outcomes such as NWAU uplift in Australia?

• How does clinical documentation improvement reduce costs related to readmissions, length of stay, and adverse events?

3. Clinician Engagement and Behavioural Change

• Which communication strategies are most effective in changing clinician documentation behaviour?

• How do interpersonal styles, personalities, and team dynamics influence CDS–clinician collaboration?

4. Professional Identity and Role Recognition

• How do CDSs describe their role within multidisciplinary healthcare teams?

• What are the pathways to credentialing, certification, and formal recognition of the CDS profession?

5. Education and Competency Development

• What are the core competencies of an effective Clinical Documentation Specialist, and how should they be assessed?

• Which professional development models such as simulation, e-learning, or workshops lead to long-term impact?

6. Technology and Digital Innovation

• How can AI and natural language processing enhance but not replace the CDS role?

• What are the benefits and risks of integrating digital documentation tools into CDI practice?

7. Workforce Sustainability in CDI

• What recruitment and retention strategies are most effective in supporting CDSs, especially in rural and regional healthcare?

• How do workload, role clarity, and organisational culture influence CDS job satisfaction and professional growth?

Building the Science of Clinical Documentation Improvement

Professionalisation of the CDS role requires more than on-the-job learning. It requires an expanding body of research that demonstrates outcomes, shapes standards, and builds credibility within the wider healthcare system. Each study, whether small-scale audits or large workforce reviews, contributes to the science of CDI and positions Clinical Documentation Specialists as leaders in documentation quality.

"Research is the foundation of professional growth. For Clinical Documentation Specialists, it is the key to transforming CDI from practice into a recognised profession that improves healthcare outcomes and strengthens patient care."