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.

Job Task

• 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/clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others to get additional information and by participating in the coding team's regular meetings.
• Train medical records staff.
• Assign the patient to one of several hundred "diagnosis-related groups", or 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.
• 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.
• Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, and 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, and use of hospital beds.
• Develop in-service educational materials.

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