Medical Record or Health Information Technician
Other Titles
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)
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.
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.
Getting Information→ Observing, receiving, and otherwise obtaining information from all relevant sources.
Processing Information→ Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
Documenting/Recording Information→ Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
Interacting With Computers→ Using computers and computer systems (including hardware and software to program, write software, set up functions, enter data, or process information.
Organizing, Planning, and Prioritizing Work→ Developing specific goals and plans to prioritize, organize, and accomplish your work.
Communicating with Supervisors, Peers, or Subordinates→ Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.
Updating and Using Relevant Knowledge→ Keeping up-to-date technically and applying new knowledge to your job.
Establishing and Maintaining Interpersonal Relationships→ Developing constructive and cooperative working relationships with others, and maintaining them over time.
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.
Performing Administrative Activities→ Performing day-to-day administrative tasks such as maintaining information files and processing paperwork.
Analyzing Data or Information→ Identifying the underlying principles, reasons, or facts of information by breaking down information or data into separate parts.
Identifying Objects, Actions, and Events→ Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
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.
Monitor Processes, Materials, or Surroundings→ Monitoring and reviewing information from materials, events, or the environment, to detect or assess problems.
Making Decisions and Solving Problems→ Analyzing information and evaluating results to choose the best solution and solve problems.
Monitor medical facility activities to ensure adherence to standards or regulations.
Process healthcare paperwork.
Perform clerical work in medical settings.
Enter patient or treatment data into computers.
Maintain medical facility records.
Present medical research reports.
Process medical billing information.
Record patient medical histories.
Manage healthcare operations.
Supervise medical support personnel.
Prepare official health documents or records.
Train caregivers or other non-medical personnel.
Maintain medical or professional knowledge.
Prepare healthcare training materials.
Near Vision→ The ability to see details at close range (within a few feet of the observer).
Oral Comprehension→ The ability to listen to and understand information and ideas presented through spoken words and sentences.
Written Comprehension→ The ability to read and understand information and ideas presented in writing.
Oral Expression→ The ability to communicate information and ideas in speaking so others will understand.
Category Flexibility→ The ability to generate or use different sets of rules for combining or grouping things in different ways.
Deductive Reasoning→ The ability to apply general rules to specific problems to produce answers that make sense.
Information Ordering→ The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g. , patterns of numbers, letters, words, pictures, mathematical operations).
Speech Recognition→ The ability to identify and understand the speech of another person.
Written Expression→ The ability to communicate information and ideas in writing so others will understand.
Clerical→ Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology.
Language→ Knowledge of the structure and content of a language - English, French, Swahili et cetera - including the meaning and spelling of words, rules of composition, and grammar.
Computers and Electronics→ Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
Customer and Personal Service→ Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
Accounting software -- Billing software
Analytical or scientific software -- Statistical software; statistical data analysis software; IBM SPSS Statistics; Minitab; SAS; StataCorp Stata
Business intelligence and data analysis software -- e.g., Zoho Analytics; MicroStrategy; Tableau; Qlik Tech QlikView; IBM Cognos Impromptu
Calendar and scheduling software -- Medical appointment scheduling; Scheduling software; Siemens Soarian Scheduling
Categorization or classification software -- Computerized indexing systems; M Encoder; Procedural terminology coding; Healthcare Common Procedure Coding System (HCPCS codes
Database management system software -- Teradata Database
Database reporting software -- e.g., SQL Server Reporting Services; SAP Crystal Reports; SoftMed ChartRelease
Database user interface and query software -- Data entry software; Structured query language SQL; Entity software; Encoded archival system EAD; Microsoft Access; Microsoft SQL Server
Development environment software -- Microsoft Visual Basic; Microsoft Visual Basic Scripting Edition VBScript
Document management software
Electronic mail software -- e.g., Microsoft Outlook
Enterprise application integration software -- IBM InfoSphere DataStage
Enterprise resource planning ERP software -- e.g., Odoo; Sage; Xero; Sapama; ebizframe; Macro 2000; SYSPRO ERP; QuickEasy BOS; TrueERP; Microsoft Dynamics; NetSuite ERP; Oracle Hyperion; SAP
Expert system software -- Medical billing and coding books
Graphics or photo imaging software -- e.g., Adobe Systems Adobe Photoshop; GNU Image Manipulation Program GIMP; Microsoft Visio; Trimble SketchUp Pro; SmugMug Flickr
Information retrieval or search software -- Coding database software
Internet browser software -- e.g., Apple Safari; Windows Explorer; Google Chrome; Mozilla Firefox
Medical software -- Digital Imaging Communications in Medicine DICOM medical imaging software; Electronic medical record EMR software; Electronic medical record EMR systems; Healthcare common procedure coding system HCPCS; Medical condition coding software; Medical procedure coding software
Metadata management software -- CA Erwin Data Modeler
Object or component oriented development software -- e.g., C#; Apache Groovy; Advanced business application programming ABAP; C++; Python; Scala; Practical extraction and reporting language Perl; Microsoft ActiveX
Office suite software — Corel WordPerfect; Microsoft Office
Operating system software -- e.g., Apple macOS; Bash; Hewlett Packard HP-UX; Job control language JCL; KornShell; Linux; Microsoft Windows; Oracle Solaris; Red Hat Enterprise Linux; Shell script; Ubuntu; UNIX
Optical character reader OCR or scanning software -- Image scanning software; Scantron imaging software
Presentation software -- e.g., Google Slides; Corel Presentations; Microsoft PowerPoint
Project management software -- e.g., Confluence; Sapama Projects; Sciforma PPM solution; Xero Projects; Microsoft Project; Easy Projects; Microsoft SharePoint; Oracle Primavera Enterprise Project Portfolio Management
Spreadsheet software -- e.g., Corel Quattro Pro; Microsoft Excel; Google Sheets; IBM Lotus --
Transaction security and virus protection software -- Encoder software; McAfee; Symantec; Kaspersky
Voice recognition software -- Speech recognition software; Voice dictation software
Word processing software -- e.g., Corel Wordperfect; Microsoft Word; Google Docs
Bar code reader equipment→ Barcode scanners
Compact disc CD or labeling printers→ Label printers
Desktop calculator→ 10-key calculators
Desktop computers
Dictation machines→ Dictaphones
Encoder decoder equipment→ Encoders
Laser fax machine→ Laser facsimile machines
Laser printers
Light stylus→ Light pens
Magnetic stripe readers and encoders→ Credit card processing machines
Medical charting systems components or accessories→ Barcode attachment equipment
Microfiche or microfilm viewer components or accessories→ Microfiche viewing machines; Microfilm viewing machines
Notebook computers
Optical character recognition systems→ Optical readers and writers
Paper shredding machines or accessories→ Paper shredders
Personal computers
Postal scales
Premise branch exchange PBX systems→ Switchboards
Scanners→ Flat-top scanners
Special purpose telephones→ Multi-line telephone systems
Tablet computers
Touch screen monitors
Typewriters
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.
Attention to Detail→ Job requires being careful about detail and thorough in completing work tasks.
Cooperation→ Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
Dependability→ Job requires being reliable, responsible, and dependable, and fulfilling obligations.
Integrity→ Job requires being honest and ethical.
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.
Initiative→ Job requires a willingness to take on responsibilities and challenges.
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.
Analytical Thinking→ Job requires analyzing information and using logic to address work-related issues and problems.
Achievement/Effort→ Job requires establishing and maintaining personally challenging achievement goals and exerting effort toward mastering tasks.
Concern for Others→ Job requires being sensitive to others' needs and feelings and being understanding and helpful on the job.
Persistence→ Job requires persistence in the face of obstacles.
Stress Tolerance→ Job requires accepting criticism and dealing calmly and effectively with high stress situations.
Social Orientation→ Job requires preferring to work with others rather than alone, and being personally connected with others on the job.
Leadership→ Job requires a willingness to lead, take charge, and offer opinions and direction.
Innovation→ Job requires creativity and alternative thinking to develop new ideas for and answers to work-related problems.
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.