Medical Records and Health Information Technicians

Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system.

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notecard with portrait profile Sample Job Titles

Coder, Health Information Clerk, Health Information Specialist, Health Information Technician (Health Information Tech), Medical Records Analyst, Medical Records Clerk, Medical Records Coordinator, Medical Records Director, Medical Records Technician (Medical Records Tech), Registered Health Information Technician (RHIT)

ringing bell Tasks
  • Protect the security of medical records to ensure that confidentiality is maintained.
  • Review records for completeness, accuracy, and compliance with regulations.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.
  • Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  • Process patient admission or discharge documents.
  • Transcribe medical reports.
  • Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.

bar graph of increasing height from left to right Knowledge
  • Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology.
English Language
  • Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.

star Skills
Reading Comprehension
  • Understanding written sentences and paragraphs in work related documents.

curved arrow betewen an x and a solid circle Abilities
Near Vision
  • The ability to see details at close range (within a few feet of the observer).
Oral Comprehension
  • The ability to listen to and understand information and ideas presented through spoken words and sentences.
Written Comprehension
  • The ability to read and understand information and ideas presented in writing.

binoculars Interests
  • Conventional occupations frequently involve following set procedures and routines. These occupations can include working with data and details more than with ideas. Usually there is a clear line of authority to follow.
  • Enterprising occupations frequently involve starting up and carrying out projects. These occupations can involve leading people and making many decisions. Sometimes they require risk taking and often deal with business.

mug with steam off the top Work styles
Attention to Detail
  • Job requires being careful about detail and thorough in completing work tasks.
  • Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
  • Job requires being reliable, responsible, and dependable, and fulfilling obligations.
  • Job requires being honest and ethical.
  • Job requires developing one's own ways of doing things, guiding oneself with little or no supervision, and depending on oneself to get things done.

wrench Tools
Bar code reader equipment
  • Barcode scanners
Compact disc CD or labeling printers
  • Label printers
Desktop calculator
  • 10-key calculators
Microfiche or microfilm viewer components or accessories
  • Microfiche viewing machines; Microfilm viewing machines
  • Flat-top scanners; Scanners

monitor Technology
Accounting software
  • Billing software; NDCMedisoft; QMSoftware Receivables Management; Siemens Soarian Financials
Categorization or classification software
  • 3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG grouping software
Data base user interface and query software
  • Data entry software; Encoded archival system EAD; EndoSoft; Entity software; Fox Meadows ChartingPlus
Document management software
  • Fox Meadows Accent Data Manager; Hyland Software OnBase; IDX Systems Patient Chart Tracking; Laserfiche software; SoftMed ChartLocater
Medical software
  • Allscripts HER; Amazing Charts; Azalea Health Azalea EHR; ComChart EMR; Digital Imaging Communications in Medicine DICOM medical imaging software
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