Medical Records & Health Information Technician

OVERVIEW

Medical Records and Health Information Technician: in the Healthcare Industry is also known as a Medical Records Clerk, Health Information Clerk, Medical Records Technician, File Clerk, Medical Records Coordinator and Medical Records Analyst.

 

 

JOB DESCRIPTION

Medical Records and Health information Technician 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. They process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry’s numerical coding system.

 

PERSONAL ATTRIBUTES

Medical records and health information technician should have the ability to understand and follow complex technical instructions, ability to pay close attention to detail, ability to effectively use computer applications, familiarity with the techniques of maintaining a filing system, accuracy, dependability, meticulous, communicative, a passion for helping people, experience in medical environment and terminology the correct specification to curb the chances of it getting lost.

TRAINING OUTCOMES
  • 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 informationPrepare statistical reports, narrative reports, or graphic presentations of information for use by hospital staff, researchers, or other users