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.
Also called: Coder · Health Information Clerk · Health Information Specialist · Health Information Technician (Health Information Tech) · Medical Records Clerk · Medical Records Coordinator
What the numbers say
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What they actually do
Core O*NET tasks for this role.
- 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.
- Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
- Post medical insurance billings.
- Process and prepare business or government forms.
- Process patient admission or discharge documents.
- Protect the security of medical records to ensure that confidentiality is maintained.
Tools & technology
- Epic Systems
- Microsoft Excel
- Microsoft Office software
- Microsoft Outlook
- eClinicalWorks EHR software
- Henry Schein Dentrix
- IBM SPSS Statistics
- MEDITECH software
- Microsoft SQL Server
- Microsoft SQL Server Reporting Services SSRS
- Microsoft Visio
- Microsoft Visual Basic
- Microsoft Windows
- R
- SAS
- Structured query language SQL