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Medical Records and Health Information Technicians Career

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 in a manner consistent with the healthcare industry's numerical coding system.

What Job Titles Medical Records and Health Information Technicians Might Have

  • Coder
  • Health Information Specialist
  • Medical Records Analyst
  • Medical Records Clerk

What Medical Records and Health Information Technicians Do

  • 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.

What Medical Records and Health Information Technicians Should Be Good At

  • 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.

What Medical Records and Health Information Technicians Should Be Interested In

  • 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.

What Medical Records and Health Information Technicians Need to Learn

  • 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.
  • English Language - Knowledge of the structure and content of the English language 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.
Sun iconThis career has a bright outlook.
Median Salary: $38,040

This page includes information from O*NET OnLine by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA). Used under the CC BY 4.0 license.