Career summary

Details for Medical Records and Health Information Technicians


Description

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.

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.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Identify, compile, abstract, and code patient data, using standard classification systems.
  • Release information to persons or agencies according to regulations.
  • Plan, develop, maintain, or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
  • Prepare statistical reports, narrative reports, or graphic presentations of information, such as tumor registry data for use by hospital staff, researchers, or other users.
  • Post medical insurance billings.
  • Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
  • Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department.
  • Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
  • Train medical records staff.
  • Process and prepare business or government forms.
  • Consult classification manuals to locate information about disease processes.
  • Develop in-service educational materials.

Interests

  • 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.

Knowledge

  • 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.

Skills

Related careers

  • Correspondence Clerks
  • Insurance Claims Clerks
  • Insurance Policy Processing Clerks
  • Office Clerks, General
  • Payroll and Timekeeping Clerks
  • Pharmacy Technicians
  • Procurement Clerks