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)
- 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.
- Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
- 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.
- Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
- Understanding written sentences and paragraphs in work related documents.
- The ability to see details at close range (within a few feet of the observer).
- The ability to listen to and understand information and ideas presented through spoken words and sentences.
- The ability to read and understand information and ideas presented in writing.
- 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.
- 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.
- Microfiche viewing machines; Microfilm viewing machines
- Flat-top scanners; Scanners
IBM SPSS Statistics; Minitab; SAS; StataCorp Stata
3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG grouping software
Data entry software; Encoded archival system EAD; EndoSoft; Entity software; Fox Meadows ChartingPlus
Fox Meadows Accent Data Manager; Hyland Software OnBase; IDX Systems Patient Chart Tracking; Laserfiche software; SoftMed ChartLocater
Allscripts HER; Amazing Charts; Azalea Health Azalea EHR; ComChart EMR; Digital Imaging Communications in Medicine DICOM medical imaging software