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.

Tasks

  • 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.
  • 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.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
  • Process and prepare business or government forms.
  • Process patient admission or discharge documents.
  • Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  • Transcribe medical reports.
  • Identify, compile, abstract, and code patient data, using standard classification systems.
  • 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.
  • Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
  • Post medical insurance billings.
  • Train medical records staff.
  • Prepare statistical reports, narrative reports, or graphic presentations of information, such as tumor registry data for use by hospital staff, researchers, or other users.
  • Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department.
  • Develop in-service educational materials.
  • Consult classification manuals to locate information about disease processes.

Knowledge

Therapy and Counseling
Knowledge of principles, methods, and procedures for diagnosis, treatment, and rehabilitation of physical and mental dysfunctions, and for career counseling and guidance.
Chemistry
Knowledge of the chemical composition, structure, and properties of substances and of the chemical processes and transformations that they undergo. This includes uses of chemicals and their interactions, danger signs, production techniques, and disposal methods.
Engineering and Technology
Knowledge of the practical application of engineering science and technology. This includes applying principles, techniques, procedures, and equipment to the design and production of various goods and services.
Fine Arts
Knowledge of the theory and techniques required to compose, produce, and perform works of music, dance, visual arts, drama, and sculpture.

Skills

Science
Using scientific rules and methods to solve problems.
Quality Control Analysis
Conducting tests and inspections of products, services, or processes to evaluate quality or performance.
Management of Financial Resources
Determining how money will be spent to get the work done, and accounting for these expenditures.
Repairing
Repairing machines or systems using the needed tools.
Troubleshooting
Determining causes of operating errors and deciding what to do about it.
Equipment Maintenance
Performing routine maintenance on equipment and determining when and what kind of maintenance is needed.
Operation and Control
Controlling operations of equipment or systems.
Installation
Installing equipment, machines, wiring, or programs to meet specifications.
Equipment Selection
Determining the kind of tools and equipment needed to do a job.
Management of Material Resources
Obtaining and seeing to the appropriate use of equipment, facilities, and materials needed to do certain work.

Abilities

Spatial Orientation
The ability to know your location in relation to the environment or to know where other objects are in relation to you.
Wrist-Finger Speed
The ability to make fast, simple, repeated movements of the fingers, hands, and wrists.
Depth Perception
The ability to judge which of several objects is closer or farther away from you, or to judge the distance between you and an object.
Peripheral Vision
The ability to see objects or movement of objects to one's side when the eyes are looking ahead.
Night Vision
The ability to see under low light conditions.
Dynamic Flexibility
The ability to quickly and repeatedly bend, stretch, twist, or reach out with your body, arms, and/or legs.
Explosive Strength
The ability to use short bursts of muscle force to propel oneself (as in jumping or sprinting), or to throw an object.
Reaction Time
The ability to quickly respond (with the hand, finger, or foot) to a signal (sound, light, picture) when it appears.
Rate Control
The ability to time your movements or the movement of a piece of equipment in anticipation of changes in the speed and/or direction of a moving object or scene.
Sound Localization
The ability to tell the direction from which a sound originated.

Work Activities

Repairing and Maintaining Mechanical Equipment
Servicing, repairing, adjusting, and testing machines, devices, moving parts, and equipment that operate primarily on the basis of mechanical (not electronic) principles.
Operating Vehicles, Mechanized Devices, or Equipment
Running, maneuvering, navigating, or driving vehicles or mechanized equipment, such as forklifts, passenger vehicles, aircraft, or water craft.

Interests

Conventional
Conventional occupations frequently involve following set procedures and routines. These occupations can include working with data and details more than with ideas. Usually there is a clear line of authority to follow.
Enterprising
Enterprising occupations frequently involve starting up and carrying out projects. These occupations can involve leading people and making many decisions. Sometimes they require risk taking and often deal with business.
Social
Social occupations frequently involve working with, communicating with, and teaching people. These occupations often involve helping or providing service to others.
Realistic
Realistic occupations frequently involve work activities that include practical, hands-on problems and solutions. They often deal with plants, animals, and real-world materials like wood, tools, and machinery. Many of the occupations require working outside, and do not involve a lot of paperwork or working closely with others.
Investigative
Investigative occupations frequently involve working with ideas, and require an extensive amount of thinking. These occupations can involve searching for facts and figuring out problems mentally.
Artistic
Artistic occupations frequently involve working with forms, designs and patterns. They often require self-expression and the work can be done without following a clear set of rules.

Work Style

Attention to Detail
Job requires being careful about detail and thorough in completing work tasks.
Integrity
Job requires being honest and ethical.
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.
Cooperation
Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
Adaptability/Flexibility
Job requires being open to change (positive or negative) and to considerable variety in the workplace.
Self Control
Job requires maintaining composure, keeping emotions in check, controlling anger, and avoiding aggressive behavior, even in very difficult situations.
Concern for Others
Job requires being sensitive to others' needs and feelings and being understanding and helpful on the job.
Initiative
Job requires a willingness to take on responsibilities and challenges.
Stress Tolerance
Job requires accepting criticism and dealing calmly and effectively with high stress situations.

Work Values

Relationships
Occupations that satisfy this work value allow employees to provide service to others and work with co-workers in a friendly non-competitive environment. Corresponding needs are Co-workers, Moral Values and Social Service.
Support
Occupations that satisfy this work value offer supportive management that stands behind employees. Corresponding needs are Company Policies, Supervision: Human Relations and Supervision: Technical.
Independence
Occupations that satisfy this work value allow employees to work on their own and make decisions. Corresponding needs are Creativity, Responsibility and Autonomy.
Working Conditions
Occupations that satisfy this work value offer job security and good working conditions. Corresponding needs are Activity, Compensation, Independence, Security, Variety and Working Conditions.
Achievement
Occupations that satisfy this work value are results oriented and allow employees to use their strongest abilities, giving them a feeling of accomplishment. Corresponding needs are Ability Utilization and Achievement.
Recognition
Occupations that satisfy this work value offer advancement, potential for leadership, and are often considered prestigious. Corresponding needs are Advancement, Authority, Recognition and Social Status.

Lay Titles

Administrative Support Assistant
Bill Pay Clerk
Certified Coding Specialist
Certified Medical Coder
Certified Professional Coder (CPC)
Clerk
Clinical Analyst
Clinical Data Manager
Clinical Data Specialist
Clinical Office Technician
Clinical Secretary
Coder
Compliance Coordinator
Disability Rater
Document Control Specialist
File Clerk
Filer
Health Information Administrator
Health Information Clerk
Health Information Coder
Health Information Management Clerk
Health Information Management Specialist
Health Information Management Technician
Health Information Specialist
Health Information Systems Technician
Health Record Technician
Health Unit Clerk
Hipaa Compliance Officer
Historian
Hospital Unit Clerk
ICD-9 Coder (International Classification of Diseases Coder)
Insurance Coder
Library Historian
Medical Administrative Specialist
Medical Administrative Technician
Medical Biller Coder
Medical Billing and Coding Specialist
Medical Billing Coder
Medical Billing Specialist
Medical Care Evaluation Specialist
Medical Claims Processor
Medical Clerk
Medical Coding Technician
Medical Insurance Coder
Medical Office Technician
Medical Record Assistant
Medical Record Coder
Medical Record Consultant
Medical Record Specialist
Medical Records Analyst
Medical Records Clerk
Medical Records Coordinator
Medical Records Custodian
Medical Records Director
Medical Records Manager
Medical Records Technician
Medical Reimbursement Specialist
Medical Secretary
Medical Transcriptionist
Office Manager
Public Health Registrar
Receptionist
Registered Health Information Technician (RHIT)
Release of Information Specialist
Severity of Illness Coordinator
Tumor Registrar

National Wages and Employment Info

Median Wages (2008):
$16.42 hourly, $34,160 annual.
Employment (2008):
182,370 employees