Medical Records and Health Info Technicians
Medical Records and Health Information Technicians
29-2071.00
Median wages
$80,090
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.
- 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 information.
- Prepare statistical reports, narrative reports, or graphic presentations of information, such as tumor registry data for use by hospital staff, researchers, or other users.
- Post medical insurance billings.
- Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
- Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department.
- Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
- Train medical records staff.
- Process and prepare business or government forms.
- Consult classification manuals to locate information about disease processes.
- Develop in-service educational materials.
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- Accounting software — Billing software; NDCMedisoft; QMSoftware Receivables Management; Siemens Soarian Financials
- Analytical or scientific software — Minitab
; SAS ; SPSS ; StataCorp Stata - Calendar and scheduling software — MD Synergy Medical Appointment Scheduling; Scheduling software; Siemens Soarian Scheduling
- Categorization or classification software — 3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG grouping software
- Data base reporting software — Microsoft SQL Server Reporting Services ; SAP Crystal Reports ; SoftMed ChartRelease
- Data base user interface and query software — Data entry software ; Fox Meadows ChartingPlus; Microsoft Access ; Purkinje Dossier
- Document management software — Fox Meadows Accent Data Manager; Hyland Software OnBase; SoftMed ChartLocater; SoftMed ChartReserve
- Electronic mail software — Email software; Microsoft Outlook
- Enterprise resource planning ERP software — SAP Business Objects
- Expert system software — Information Resource Products Clinical Coding Expert
- Graphics or photo imaging software — Graphics software; Microsoft Visio
- Information retrieval or search software — Coding database software
- Internet browser software — Web browser software
- Medical software — Epic Systems ; Medical condition coding software ; Medical procedure coding software ; MEDITECH software
- Office suite software — Corel WordPerfect; Microsoft Office
- Optical character reader OCR or scanning software — Scantron imaging software
- Presentation software — Microsoft PowerPoint
- Spreadsheet software — IBM Lotus 1-2-3; Microsoft Excel
- Transaction security and virus protection software — Encoder software
- Voice recognition software — Cyber Records MediChart Express; ScanSoft Naturally Speaking; Speech recognition software; Voice dictation software
- Word processing software — Microsoft Word
- Accounting software — Billing software; NDCMedisoft; QMSoftware Receivables Management; Siemens Soarian Financials
- Reading Comprehension — Understanding written sentences and paragraphs in work related documents.
- 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.
- Speaking — Talking to others to convey information effectively.
- Writing — Communicating effectively in writing as appropriate for the needs of the audience.
