Medical Records Specialist

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.

O*NET reports this occupation under titles such as: Coder; Health Information Clerk; Health Information Specialist; Health Information Technician (Health Information Tech); Health Records Specialist; HIM Clerk (Health Information Management Clerk); Medical Coder; Medical Records Clerk; Medical Records Technician (Medical Records Tech); RHIT (Registered Health Information Technician)

Tasks

• Protect the security of medical records to ensure that confidentiality is maintained.
• Review records for completeness, accuracy, and compliance with regulations.
• Scan patients' health records into electronic formats.
• Release information to persons or agencies according to regulations.
• Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
• Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
• Process patient admission or discharge documents.
• Retrieve patient medical records for physicians, technicians, or other medical personnel.

Knowledge

• Administrative
• English Language
• Customer and Personal Service
• Computers and Electronics
• Administration and Management

Skills

• Reading Comprehension
• Critical Thinking
• Active Listening
• Writing
• Speaking
• Active Learning
• Monitoring

Abilities

• Written Comprehension
• Oral Comprehension
• Near Vision
• Information Ordering
• Category Flexibility
• Oral Expression
• Written Expression
• Speech Recognition
• Deductive Reasoning
• Selective Attention
• Speech Clarity
• Inductive Reasoning