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.
- 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.
Knowledge
- 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.
- Customer and Personal Service
- Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
- Computers and Electronics
- Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
- Law and Government
- Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.
- Public Safety and Security
- Knowledge of relevant equipment, policies, procedures, and strategies to promote effective local, state, or national security operations for the protection of people, data, property, and institutions.
- Education and Training
- Knowledge of principles and methods for curriculum and training design, teaching and instruction for individuals and groups, and the measurement of training effects.
- Mathematics
- Knowledge of arithmetic, algebra, geometry, calculus, statistics, and their applications.
- Telecommunications
- Knowledge of transmission, broadcasting, switching, control, and operation of telecommunications systems.
- Administration and Management
- Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources.
Skills
- Active Listening
- Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
- Reading Comprehension
- Understanding written sentences and paragraphs in work related documents.
- Monitoring
- Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.
- Speaking
- Talking to others to convey information effectively.
- Critical Thinking
- Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
- Complex Problem Solving
- Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
- Time Management
- Managing one's own time and the time of others.
- Coordination
- Adjusting actions in relation to others' actions.
- Judgment and Decision Making
- Considering the relative costs and benefits of potential actions to choose the most appropriate one.
- Social Perceptiveness
- Being aware of others' reactions and understanding why they react as they do.
Abilities
- Near Vision
- The ability to see details at close range (within a few feet of the observer).
- Oral Expression
- The ability to communicate information and ideas in speaking so others will understand.
- Information Ordering
- The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations).
- Problem Sensitivity
- The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
- Written Comprehension
- The ability to read and understand information and ideas presented in writing.
- Speech Recognition
- The ability to identify and understand the speech of another person.
- Speech Clarity
- The ability to speak clearly so others can understand you.
- Category Flexibility
- The ability to generate or use different sets of rules for combining or grouping things in different ways.
- Finger Dexterity
- The ability to make precisely coordinated movements of the fingers of one or both hands to grasp, manipulate, or assemble very small objects.
- Deductive Reasoning
- The ability to apply general rules to specific problems to produce answers that make sense.
Work Activities
- Getting Information
- Observing, receiving, and otherwise obtaining information from all relevant sources.
- Interacting With Computers
- Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
- Organizing, Planning, and Prioritizing Work
- Developing specific goals and plans to prioritize, organize, and accomplish your work.
- Establishing and Maintaining Interpersonal Relationships
- Developing constructive and cooperative working relationships with others, and maintaining them over time.
- Evaluating Information to Determine Compliance with Standards
- Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.
- Communicating with Supervisors, Peers, or Subordinates
- Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.
- Performing Administrative Activities
- Performing day-to-day administrative tasks such as maintaining information files and processing paperwork.
- Identifying Objects, Actions, and Events
- Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
- Processing Information
- Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
- Documenting/Recording Information
- Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
Work Context
- Telephone
- How often do you have telephone conversations in this job?
- Importance of Being Exact or Accurate
- How important is being very exact or highly accurate in performing this job?
- Indoors, Environmentally Controlled
- How often does this job require working indoors in environmentally controlled conditions?
- Contact With Others
- How much does this job require the worker to be in contact with others (face-to-face, by telephone, or otherwise) in order to perform it?
- Face-to-Face Discussions
- How often do you have to have face-to-face discussions with individuals or teams in this job?
- Structured versus Unstructured Work
- To what extent is this job structured for the worker, rather than allowing the worker to determine tasks, priorities, and goals?
- Importance of Repeating Same Tasks
- How important is repeating the same physical activities (e.g., key entry) or mental activities (e.g., checking entries in a ledger) over and over, without stopping, to performing this job?
- Work With Work Group or Team
- How important is it to work with others in a group or team in this job?
- Time Pressure
- How often does this job require the worker to meet strict deadlines?
- Freedom to Make Decisions
- How much decision making freedom, without supervision, does the job offer?
Interests
- 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.
- 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.
- Social
- Social occupations frequently involve working with, communicating with, and teaching people. These occupations often involve helping or providing service to others.
- Realistic
- Realistic occupations frequently involve work activities that include practical, hands-on problems and solutions. They often deal with plants, animals, and real-world materials like wood, tools, and machinery. Many of the occupations require working outside, and do not involve a lot of paperwork or working closely with others.
- Investigative
- Investigative occupations frequently involve working with ideas, and require an extensive amount of thinking. These occupations can involve searching for facts and figuring out problems mentally.
- Artistic
- Artistic occupations frequently involve working with forms, designs and patterns. They often require self-expression and the work can be done without following a clear set of rules.
Work Style
- Attention to Detail
- Job requires being careful about detail and thorough in completing work tasks.
- Integrity
- Job requires being honest and ethical.
- Dependability
- Job requires being reliable, responsible, and dependable, and fulfilling obligations.
- Independence
- Job requires developing one's own ways of doing things, guiding oneself with little or no supervision, and depending on oneself to get things done.
- Cooperation
- Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
- Adaptability/Flexibility
- Job requires being open to change (positive or negative) and to considerable variety in the workplace.
- Self Control
- Job requires maintaining composure, keeping emotions in check, controlling anger, and avoiding aggressive behavior, even in very difficult situations.
- Concern for Others
- Job requires being sensitive to others' needs and feelings and being understanding and helpful on the job.
- Stress Tolerance
- Job requires accepting criticism and dealing calmly and effectively with high stress situations.
- Initiative
- Job requires a willingness to take on responsibilities and challenges.
Work Value
- Relationships
- Occupations that satisfy this work value allow employees to provide service to others and work with co-workers in a friendly non-competitive environment. Corresponding needs are Co-workers, Moral Values and Social Service.
- Support
- Occupations that satisfy this work value offer supportive management that stands behind employees. Corresponding needs are Company Policies, Supervision: Human Relations and Supervision: Technical.
- Independence
- Occupations that satisfy this work value allow employs to work on their own and make decisions. Corresponding needs are Creativity, Responsibility and Autonomy.
- Working Conditions
- Occupations that satisfy this work value offer job security and good working conditions. Corresponding needs are Activity, Compensation, Independence, Security, Variety and Working Conditions.
- Achievement
- Occupations that satisfy this work value are results oriented and allow employees to use their strongest abilities, giving them a feeling of accomplishment. Corresponding needs are Ability Utilization and Achievement.
- Recognition
- Occupations that satisfy this work value offer advancement, potential for leadership, and are often considered prestigious. Corresponding needs are Advancement, Authority, Recognition and Social Status.
Related Occupations
- Pharmacy Technicians
- Payroll and Timekeeping Clerks
- Procurement Clerks
- Correspondence Clerks
- Insurance Claims Clerks
- Insurance Policy Processing Clerks
- Office Clerks, General
Common Lay Titles
- Administrative Support Assistant
- Bill Pay Clerk
- Certified Coding Specialist
- Certified Medical Coder
- Certified Professional Coder (CPC)
- Clerk
- Clinical Analyst
- Clinical Data Manager
- Clinical Data Specialist
- Clinical Office Technician
- Clinical Secretary
- Coder
- Compliance Coordinator
- Disability Rater
- Document Control Specialist
- File Clerk
- Filer
- Health Information Administrator
- Health Information Clerk
- Health Information Coder
- Health Information Management Clerk
- Health Information Management Specialist
- Health Information Management Technician
- Health Information Specialist
- Health Information Systems Technician
- Health Record Technician
- Health Unit Clerk
- Hipaa Compliance Officer
- Historian
- Hospital Unit Clerk
- ICD-9 Coder (International Classification of Diseases Coder)
- Insurance Coder
- Library Historian
- Medical Administrative Specialist
- Medical Administrative Technician
- Medical Biller Coder
- Medical Billing and Coding Specialist
- Medical Billing Coder
- Medical Billing Specialist
- Medical Care Evaluation Specialist
- Medical Claims Processor
- Medical Clerk
- Medical Coding Technician
- Medical Insurance Coder
- Medical Office Technician
- Medical Record Assistant
- Medical Record Coder
- Medical Record Consultant
- Medical Record Specialist
- Medical Records Analyst
- Medical Records Clerk
- Medical Records Coordinator
- Medical Records Custodian
- Medical Records Director
- Medical Records Manager
- Medical Records Technician
- Medical Reimbursement Specialist
- Medical Secretary
- Medical Transcriptionist
- Office Manager
- Public Health Registrar
- Receptionist
- Registered Health Information Technician (RHIT)
- Release of Information Specialist
- Severity of Illness Coordinator
- Tumor Registrar