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Medical Records and Health Information Technicians
SOC Code: 29-2071.00

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.

Sample of reported job 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), Registered Health Information Technician (RHIT)

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.
  • 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.

Technology Skills

  • Accounting software - Billing software; NDCMedisoft; QMSoftware Receivables Management; Siemens Soarian Financials
  • Analytical or scientific software - IBM SPSS Statistics ; Minitab ; SAS ; StataCorp Stata
  • Business intelligence and data analysis software - MicroStrategy ; Tableau
  • Calendar and scheduling software - MD Synergy Medical Appointment Scheduling; Scheduling software; Siemens Soarian Scheduling
  • Categorization or classification software - 3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG grouping software
  • Data base reporting software - Microsoft SQL Server Reporting Services ; SAP Crystal Reports ; SoftMed ChartRelease
  • Data base user interface and query software - Data entry software ; Encoded archival system EAD; Fox Meadows ChartingPlus; Microsoft Access (see all 7 examples)
  • Document management software - Fox Meadows Accent Data Manager; Hyland Software OnBase; IDX Systems Patient Chart Tracking; SoftMed ChartLocater (see all 6 examples)
  • Electronic mail software - Email software; Microsoft Outlook
  • Enterprise resource planning ERP software - SAP Business Objects
  • Expert system software - Information Resource Products Clinical Coding Expert
  • Graphics or photo imaging software - Graphics software; Microsoft Visio
  • Information retrieval or search software - Coding database software
  • Internet browser software - Web browser software
  • Medical software - Epic Systems ; Healthcare common procedure coding system HCPCS ; Medical condition coding software ; MEDITECH software (see all 39 examples)
  • Object or component oriented development software - R
  • Office suite software - Corel WordPerfect; Microsoft Office
  • Operating system software - Microsoft Windows
  • Optical character reader OCR or scanning software - Scantron imaging software
  • Presentation software - Microsoft PowerPoint
  • Spreadsheet software - IBM Lotus 1-2-3; Microsoft Excel
  • Transaction security and virus protection software - Encoder software
  • Voice recognition software - Cyber Records MediChart Express; ScanSoft Naturally Speaking; Speech recognition software; Voice dictation software
  • Word processing software - Microsoft Word

Tools Used

  • 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

Knowledge

  • 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.
  • 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.

Skills

  • 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.

Abilities

  • 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.

Interests

  • Interest code: CE
    • 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.

Work Context

  • Importance of Being Exact or Accurate - 74% responded “Extremely important.”
  • Importance of Repeating Same Tasks - 78% responded “Extremely important.”
  • Indoors, Environmentally Controlled - 86% responded “Every day.”
  • Spend Time Sitting - 66% responded “Continually or almost continually.”
  • Face-to-Face Discussions - 60% responded “Every day.”
  • Telephone - 65% responded “Every day.”
  • Work With Work Group or Team - 43% responded “Extremely important.”
  • Contact With Others - 42% responded “Contact with others most of the time.”
  • Electronic Mail - 67% responded “Every day.”
  • Structured versus Unstructured Work - 53% responded “Some freedom.”
  • Freedom to Make Decisions - 44% responded “Some freedom.”
  • Time Pressure - 40% responded “Every day.”
  • Spend Time Making Repetitive Motions - 39% responded “Continually or almost continually.”
  • Frequency of Decision Making - 56% responded “Every day.”
  • Impact of Decisions on Co-workers or Company Results - 37% responded “Important results.”
  • Sounds, Noise Levels Are Distracting or Uncomfortable - 36% responded “Every day.”
  • Coordinate or Lead Others - 42% responded “Important.”
  • Deal With External Customers - 25% responded “Extremely important.”
  • Letters and Memos - 31% responded “Never.”
  • Spend Time Using Your Hands to Handle, Control, or Feel Objects, Tools, or Controls - 38% responded “Continually or almost continually.”
  • Physical Proximity - 56% responded “Slightly close (e.g., shared office).”

Education

Percentage of RespondentsEducation Level Required
48%High school diploma or equivalent
21%Some college, no degree
20%Associate's degree

Work Styles

  • 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.

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.

Wages & Trends

  • Median wages (2017)
    • $18.83 hourly, $39,180 annual
  • Employment (2016)
    • 206,000 employees
  • Projected growth (2016-2026)
    • Faster than average (10% to 14%)
  • Projected job openings (2016-2026)
    • 15,800

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