What does a Medical Record and Health Information Technician do?

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.

Jobs Roles

  • Protect the security of medical records to ensure that confidentiality is maintained.
  • Process patient admission or 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, or treatment into computer.
  • 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.
  • Manage the department or supervise clerical workers, directing or 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 or 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 or government forms.
  • Prepare statistical reports, narrative reports, or 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.
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