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Details for 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.


  • Protect the security of medical records to ensure that confidentiality is maintained.
  • Process patient admission and discharge documents.
  • Review records for completeness, accuracy and compliance with regulations.
  • Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.
  • Release information to persons and agencies according to regulations.
  • Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
  • Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department.
  • Transcribe medical reports.
  • Identify, compile, abstract and code patient data, using standard classification systems.
  • Resolve or clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.
  • Train medical records staff.
  • Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  • Post medical insurance billings.
  • Process and prepare business and government forms.
  • Contact discharged patients, their families, and physicians to maintain registry with follow-up information, such as quality of life and length of survival of cancer patients.
  • Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, or other users.
  • Consult classification manuals to locate information about disease processes.
  • Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
  • Develop in-service educational materials.


  • Enterprising - 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.
  • Conventional - 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.

Education, Training, Experience

  • Education - Most occupations in this zone require training in vocational schools, related on-the-job experience, or an associate's degree.
  • Training - Employees in these occupations usually need one or two years of training involving both on-the-job experience and informal training with experienced workers. A recognized apprenticeship program may be associated with these occupations.
  • Experience - Previous work-related skill, knowledge, or experience is required for these occupations. For example, an electrician must have completed three or four years of apprenticeship or several years of vocational training, and often must have passed a licensing exam, in order to perform the job.


  • English Language - Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
  • Clerical - 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.


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  • Procurement Clerks
Wages for this career
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