Medical Records & 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.
JobTitles : Coder, Health Information Clerk, Health Information Specialist, Health Information Technician (Health Information Tech), Medical Records Analyst, Medical Records Clerk, Medical Records Coordinator, Medical Records Director, Medical Records Technician (Medical Records Tech), Registered Health Information Technician (RHIT)
- 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.