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Clinical Documentation Specialist

Clinical Documentation Specialist

This checklist was electronically signed on September 12, 2026

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

GENERAL NURSING

Electronic Vital Signs monitoring: TPR, BP
Manual Blood Pressure
Height and weight
Correctional Health Admissions
Assist with Routine Health Services
Assist with First Aide
Initiates Emergency Procedures
Discharge Physicals/Inmates
Supervise Unlicensed Personnel
Dental Assessment
Ear Assessment
Labor, Delivery, and Fetal Heart Tones
Phlebotomy

BASIC NURSING CARE

Pulse Oximetry
Urine Dipstick
Blood Glucose Monitoring
Assist with Basic Treatment Procedures
Wound Care/Wound Debridement
Dressing Changes
Wound Drains (JP/Hemovac)
Positioning/Transferring
Pre-Operative Care and Preparation
Universal Precautions
CDC (Center for Disease Control) Guidelines
Ambulatory Cuffs
Isolation Techniques
Wrist Restraints
Full Restraints
Alarm Systems
Cultural Diversity
Ethnic Diversity

MEDICATION/IV THERAPY

Administer PO Medications
Administer IM & SQ Meds
Peripheral IV Insertion
Use of Heparin/Saline Locks
Needle-less Systems
Administer IV Medications
Discontinue Peripheral IVs
Pain Assessment/Management
Venipuncture for Lab Work
Prepare Specimens for Lab

RESPIRATORY

Establish Airway
Assist with Intubation (ETT)
Ventilate with Ambu-Bag
Suctioning
Incentive Spirometry
Face Masks
Respiratory Treatments
Oxygen Tanks
Nasal Cannula
Assessment of Breath Sounds
Ambuing techniques

NEUROLOGY

Neuro Assessment/Vital Signs
Seizure Precautions
Assist with Lumbar Puncture

ADMINISTRATIVE DUTIES

Documentation
Maintain Clinic Flow
Order Supplies/Equipment
Assemble Medical Record
Maintain Medical Record
Manage Provider Orders
Schedule Appointments
Maintains Unit Logs/Records
Multi-Disciplinary
Management of blood transfusion
Multi-Disciplinary Planning
OSHA Guidelines
Inmate/Patient Education

CARDIAC

Cardiac Assessment Vital Signs
Perform 12-lead EKG
Assist with Code
Defibrillation/Cardioversion
Cardiac Arrest/CPR

GENITOURINARY

Straight/Foley Catheter: Female
Straight/Foley Catheter: Male
Obtain/Instruct Clean Catch Urine

GASTROINTESTINAL

Assess Bowel Sounds
Assess GI Distress/Bleeding
Insertion/Monitoring NG Tube
Tube Feedings via Flexible Tubes
Care of Patient with Abdominal Wounds
Care of Patient with Drains

CARE OF PSYCHIATRIC DISORDERS

Initial Assessment
Suicide Risk Assessment
Schizophrenia
Paranoid Psychotic Disorder
Catatonic Psychotic Disorder
Hallucinations
Bipolar Disorder
Depression
Suicidal Ideation/Attempts
Delusional Disorders
Anxiety Disorders
Panic Attacks
Phobias
Obsessive/Compulsive Disorder
Dissociative Identity Disorder
Cluster A – Paranoid/Schizoid
Cluster B – Antisocial/Borderline
Cluster C – Anxious/Fearful
Delirium
Dementia
Alzheimer’s (Demetia)
Amnestic Disorders
Anorexia Nervosa
Obesity
Survivor of Abuse/Violence
Alcohol-Related Disorders
Sexual Disorders
Sexual Abuse/Assault
Post Traumatic Stress Disorder
Somatoform Disorders (Pain, Etc.)
ADHD

INTERVENTION/THERAPIES

Crisis Intervention
Therapeutic Communication
Therapeutic Milieuv
Education or Vocational Training
Drug & Alcohol Education
ElectroConvulsive Therapy
Crisis Management: Homicide
Crisis Management: Violent Individual
Crisis Management: Suicide

PSYCHOTROPIC AGENTS

Rapid Tranquilization
Antipsychotic Agents
Hypnotics
Antianxiety Agents
Antidepressants/Mood Elevators
Anticonvulsants
Anticholinergics/Antiparkinsons

MEDICATION SIDE EFFECTS

Blurred Vision
Constipation
Drowsiness
Dry Mouth
Gastrointestinal Effects
Hypo/Hyperglycemia
Hypotension/Orthostatic
Insomnia
Tachycardia
Urinary Retention
Weight Gain
Parkinsonism Symptoms
Akathisia (Motor Restlessness)
Acute Dystonic Reactions
Tardive Dyskinesia
Neuroleptic Malignant Syndrome

ELECTRONIC DOCUMENTATION

Allscripts
Care360
Cerner
CPSI
eCLinicalWorks
Eclipsys
EPIC
MACLAB
McKesson/Paragon
Meditech
PACS
Quadramed
Soarian

AGE SPECIFIC COMPETENCIES

Newborn/Neonate (birth to 30 days)
Infant (31 days to 12 months)
Toddler (1-3 years)
Preschooler (3-5 years)
School age children (5-12 years)
Adolescents (12-18 years)
Young adults (18- 39 years)
Middle adults (39- 64 years)
Older adults (64-79 years)
Elderly adults (80+ years)