Medical Records and Health Information Technicians

Career 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.

Industry: Healthcare Practitioners and Technical

Other Job Titles for Medical Records and Health Information Technicians:

• 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.
• Social: Social occupations frequently involve working with, communicating with, and teaching people. These occupations often involve helping or providing service to others.
• 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.
• 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.
• First Interest High-Point: Primary-Rank Descriptiveness
• Second Interest High-Point: Secondary-Cutoff/Rank Descriptiveness
• Third Interest High-Point: Tertiary-Cutoff/Rank Descriptiveness

• Protect the security of medical records to ensure that confidentiality is maintained.
• Process patient admission and discharge documents.
• Review records for completeness, accuracy and compliance with regulations.
• Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
• Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.
• Release information to persons and agencies according to regulations.
• Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
• Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department.
• Transcribe medical reports.
• Identify, compile, abstract and code patient data, using standard classification systems.
• Resolve or clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.
• Train medical records staff.
• Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
• Post medical insurance billings.
• Process and prepare business and government forms.
• Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, or other users.
• Consult classification manuals to locate information about disease processes.
• Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
• Develop in-service educational materials.
• Retrieve patient medical records for physicians, technicians, or other medical personnel.
• Wash and dress bodies of deceased persons.
• Make appointments, keep records and perform other clerical duties in doctors' offices and clinics.
• Set up equipment and prepare medical treatment rooms.
• Set up 24-hour Holter and event monitors, scan and interpret tapes, and report results to physicians.

Emerging Tasks

• Set up, maintain, calibrate, clean, and test sterility of medical laboratory equipment.
• Conduct nutritional assessments of individuals, including obtaining and evaluating individuals' dietary histories, to plan nutritional programs.
• Provide clinical services and health education to improve and maintain the oral health of patients and the general public.
• Record and review patient medical histories.
• Fit, dispense, and repair assistive devices, such as hearing aids.
• Perform administrative tasks such as photocopying, filing, and managing office finances (e.g., monitoring budget, handling accounting payable and receivable).
• Plan and conduct treatment programs for clients' hearing, speech, or vertigo problems, consulting with physicians, nurses, psychologists, and other health care personnel as necessary.
• Provide information to the public, and advise educators and other medical staff on speech or hearing topics.

• Analyzing Data or Information: Identifying the underlying principles, reasons, or facts of information by breaking down information or data into separate parts.
• Assisting and Caring for Others: Providing personal assistance, medical attention, emotional support, or other personal care to others such as coworkers, customers, or patients.
• Coaching and Developing Others: Identifying the developmental needs of others and coaching, mentoring, or otherwise helping others to improve their knowledge or skills.
• 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.
• Controlling Machines and Processes: Using either control mechanisms or direct physical activity to operate machines or processes (not including computers or vehicles).
• Coordinating the Work and Activities of Others: Getting members of a group to work together to accomplish tasks.
• Developing and Building Teams: Encouraging and building mutual trust, respect, and cooperation among team members.
• Developing Objectives and Strategies: Establishing long-range objectives and specifying the strategies and actions to achieve them.
• Documenting/Recording Information: Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
• Drafting, Laying Out, and Specifying Technical Devices, Parts, and Equipment: Providing documentation, detailed instructions, drawings, or specifications to tell others about how devices, parts, equipment, or structures are to be fabricated, constructed, assembled, modified, maintained, or used.
• Establishing and Maintaining Interpersonal Relationships: Developing constructive and cooperative working relationships with others, and maintaining them over time.
• Estimating the Quantifiable Characteristics of Products, Events, or Information: Estimating sizes, distances, and quantities; or determining time, costs, resources, or materials needed to perform a work activity.
• 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.
• Guiding, Directing, and Motivating Subordinates: Providing guidance and direction to subordinates, including setting performance standards and monitoring performance.
• Handling and Moving Objects: Using hands and arms in handling, installing, positioning, and moving materials, and manipulating things.
• Identifying Objects, Actions, and Events: Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
• Inspecting Equipment, Structures, or Material: Inspecting equipment, structures, or materials to identify the cause of errors or other problems or defects.
• Interacting With Computers: Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
• Interpreting the Meaning of Information for Others: Translating or explaining what information means and how it can be used.
• Judging the Qualities of Things, Services, or People: Assessing the value, importance, or quality of things or people.
• 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.
• Monitoring and Controlling Resources: Monitoring and controlling resources and overseeing the spending of money.
• Operating Vehicles, Mechanized Devices, or Equipment: Running, maneuvering, navigating, or driving vehicles or mechanized equipment, such as forklifts, passenger vehicles, aircraft, or water craft.
• 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.
• Performing for or Working Directly with the Public: Performing for people or dealing directly with the public. This includes serving customers in restaurants and stores, and receiving clients or guests.
• Performing General Physical Activities: Performing physical activities that require considerable use of your arms and legs and moving your whole body, such as climbing, lifting, balancing, walking, stooping, and handling of materials.
• Processing Information: Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
• Provide Consultation and Advice to Others: Providing guidance and expert advice to management or other groups on technical, systems-, or process-related topics.
• Repairing and Maintaining Electronic Equipment: Servicing, repairing, calibrating, regulating, fine-tuning, or testing machines, devices, and equipment that operate primarily on the basis of electrical or electronic (not mechanical) principles.
• 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.
• Resolving Conflicts and Negotiating with Others: Handling complaints, settling disputes, and resolving grievances and conflicts, or otherwise negotiating with others.
• Scheduling Work and Activities: Scheduling events, programs, and activities, as well as the work of others.
• Selling or Influencing Others: Convincing others to buy merchandise/goods or to otherwise change their minds or actions.
• Staffing Organizational Units: Recruiting, interviewing, selecting, hiring, and promoting employees in an organization.
• Thinking Creatively: Developing, designing, or creating new applications, ideas, relationships, systems, or products, including artistic contributions.
• Training and Teaching Others: Identifying the educational needs of others, developing formal educational or training programs or classes, and teaching or instructing others.
• Updating and Using Relevant Knowledge: Keeping up-to-date technically and applying new knowledge to your job.

Detailed Work Activities

• code data from records
• collect statistical data
• create mathematical or statistical diagrams or charts
• examine documents for completeness, accuracy, or conformance to standards
• fill out business or government forms
• follow data storage procedures
• maintain dental or medical records
• obtain information from individuals
• prepare reports
• process medical records
• record medical history or data
• review records for completeness
• transcribe spoken or written information
• understand technical operating, service or repair manuals
• use computers to enter, access or retrieve data
• use interviewing procedures
• use knowledge of dental terminology
• use knowledge of medical terminology
• use oral or written communication techniques
• use relational database software
• use secretarial procedures
• use spreadsheet software
• use word processing or desktop publishing software
• draw blood
• enter analysis of medical tests or clinical results into computer for storage
• examine biological or other material specimens under microscope
• explain complex mathematical information
• follow infectious materials procedures
• follow microbiology procedures
• follow safe waste disposal procedures
• isolate and identify micro-organisms
• label blood samples
• maintain laboratory or field equipment
• maintain records, reports, or files
• monitor worker performance
• obtain technical support instructions from scientists or engineers
• perform statistical analysis
• prepare biological specimens for examination
• prepare reports
• prepare sample for laboratory testing, analysis, or microscopy
• prepare vaccines, biologicals, or serums
• record test results, test procedures, or inspection data
• research human or animal disease
• set up or calibrate laboratory equipment
• sterilize or clean laboratory or healthcare equipment
• store medical laboratory specimens
• teach individuals work-related techniques or skills
• understand technical operating, service or repair manuals
• use biological research techniques
• use biological testing instruments
• use chemical testing or analysis procedures
• use clinical sterilizing technique
• use computers to enter, access or retrieve data
• use hazardous materials information
• use health or sanitation standards
• use knowledge of investigation techniques
• use knowledge of medical terminology
• use knowledge of metric system
• use laboratory equipment
• use library or online Internet research techniques
• use mathematical or statistical methods to identify or analyze problems
• use medical lab techniques
• use microscope
• use precision measuring tools or equipment
• use quality assurance techniques
• use quantitative research methods
• use relational database software
• use research methodology procedures in health care
• use sanitation practices in health care settings
• use scientific research methodology
• use spreadsheet software
• use word processing or desktop publishing software
• verify completeness or accuracy of data

Overall Experience
Some previous work-related skill, knowledge, or experience may be helpful in these occupations, but usually is not needed. For example, a teller might benefit from experience working directly with the public, but an inexperienced person could still learn to be a teller with little difficulty.

Job Training
Employees in these occupations need anywhere from a few months to one year of working with experienced employees.

Education
These occupations usually require a high school diploma and may require some vocational training or job-related course work. In some cases, an associate's or bachelor's degree could be needed.

Examples
These occupations often involve using your knowledge and skills to help others. Examples include sheet metal workers, forest fire fighters, customer service representatives, pharmacy technicians, salespersons (retail), and tellers.

• Average hourly wage (2007) -$14.08
• Average annual wage (2007) - $29,290.00

• Projected growth (2006-2016): 17.81%
• Projected need (2006-2016): 30,224
• Employment (2006): 169,742

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