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Medical Records and Health Information Technicians

Medical Records and Health Information Technicians

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 in a manner consistent with the healthcare industry's numerical coding system.

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.
  • Critical Thinking - Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
  • Reading Comprehension - Understanding written sentences and paragraphs in work related documents.
  • Speaking - Talking to others to convey information effectively.
  • Writing - Communicating effectively in writing as appropriate for the needs of the audience.
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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.
  • Computers and Electronics - Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
  • 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.
  • English Language - Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
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Tasks

  • 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.
  • Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
  • Consult classification manuals to locate information about disease processes.
  • Develop in-service educational materials.
  • 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.
  • Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department.
  • Post medical insurance billings.
  • Process patient admission or discharge documents.
  • Prepare statistical reports, narrative reports, or graphic presentations of information, such as tumor registry data for use by hospital staff, researchers, or other users.
  • Plan, develop, maintain, or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
  • Process and prepare business or government forms.
  • Protect the security of medical records to ensure that confidentiality is maintained.
  • Release information to persons or agencies according to regulations.
  • 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.
  • Review records for completeness, accuracy, and compliance with regulations.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.
  • Transcribe medical reports.
  • Train medical records staff.
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Work Activities

  • Analyzing Data or Information - Identifying the underlying principles, reasons, or facts of information by breaking down information or data into separate parts.
  • Communicating with Persons Outside Organization - Communicating with people outside the organization, representing the organization to customers, the public, government, and other external sources. This information can be exchanged in person, in writing, or by telephone or e-mail.
  • Communicating with Supervisors, Peers, or Subordinates - Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.
  • Documenting/Recording Information - Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
  • 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.
  • Getting Information - Observing, receiving, and otherwise obtaining information from all relevant sources.
  • Identifying Objects, Actions, and Events - Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
  • Interacting With Computers - Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
  • Making Decisions and Solving Problems - Analyzing information and evaluating results to choose the best solution and solve problems.
  • Monitor Processes, Materials, or Surroundings - Monitoring and reviewing information from materials, events, or the environment, to detect or assess problems.
  • Organizing, Planning, and Prioritizing Work - Developing specific goals and plans to prioritize, organize, and accomplish your work.
  • Performing Administrative Activities - Performing day-to-day administrative tasks such as maintaining information files and processing paperwork.
  • Processing Information - Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
  • Updating and Using Relevant Knowledge - Keeping up-to-date technically and applying new knowledge to your job.
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Personality Traits

  • Achievement/Effort: Job requires establishing and maintaining personally challenging achievement goals and exerting effort toward mastering tasks.
  • Adaptability/Flexibility: Job requires being open to change (positive or negative) and to considerable variety in the workplace.
  • Analytical Thinking: Job requires analyzing information and using logic to address work-related issues and problems.
  • Attention to Detail: Job requires being careful about detail and thorough in completing work tasks.
  • Concern for Others: Job requires being sensitive to others' needs and feelings and being understanding and helpful on the job.
  • Cooperation: Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
  • 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.
  • Initiative: Job requires a willingness to take on responsibilities and challenges.
  • Innovation: Job requires creativity and alternative thinking to develop new ideas for and answers to work-related problems.
  • Integrity: Job requires being honest and ethical.
  • Leadership: Job requires a willingness to lead, take charge, and offer opinions and direction.
  • Persistence: Job requires persistence in the face of obstacles.
  • Self Control: Job requires maintaining composure, keeping emotions in check, controlling anger, and avoiding aggressive behavior, even in very difficult situations.
  • Social Orientation: Job requires preferring to work with others rather than alone, and being personally connected with others on the job.
  • Stress Tolerance: Job requires accepting criticism and dealing calmly and effectively with high stress situations.
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Related Careers

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