Medical Records Specialists
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 healthcare system. Classify medical and healthcare concepts, including diagnosis, procedures, medical services, and equipment, into the healthcare industry's numerical coding system. Includes medical coders.
Sample of reported job titles:
Coder, Health Information Clerk, Health Information Specialist, Health Information Technician (Health Information Tech), Medical Records Clerk, Medical Records Coordinator, Medical Records Technician (Medical Records Tech), Registered Health Information Technician (RHIT)
Occupation-Specific Information
Tasks
- Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
- Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
- Consult classification manuals to locate information about disease processes.
- 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.
Technology Skills
- Accounting software:Billing software,NDCMedisoft,QMSoftware Receivables Management,Siemens Soarian Financials
- Analytical or scientific software:IBM SPSS Statistics,Minitab,SAS statistical software,StataCorp Stata
- Business intelligence and data analysis software:IBM Cognos Impromptu,MicroStrategy,Qlik Tech QlikView,Tableau
- Calendar and scheduling software:MD Synergy Medical Appointment Scheduling,Scheduling software,Siemens Soarian Scheduling
- Categorization or classification software:3M Encoder,American Medical Association CodeManager,Computerized indexing systems,DRG grouping software
Occupational Requirements
Detailed Work Activities
- Classify materials according to standard systems.
- Code data or other information.
- Collect medical information from patients, family members, or other medical professionals.
- Communicate with management or other staff to resolve problems.
- Enter patient or treatment data into computers.
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