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Career 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 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.

What Job Titles Medical Records Specialists Might Have

• Coder
• Health Information Specialist
• Medical Records Analyst
• Medical Records Clerk

What Medical Records Specialists Do

• 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.

What Medical Records Specialists Should Be Good At

• 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.

What Medical Records Specialists Should Be Interested In

• 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.

What Medical Records Specialists Need to Learn

• 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.
• English Language - Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
• Computers and Electronics - Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.