Medical Records Specialists
What is a Medical Records Specialist?
A Medical Records Specialist is a healthcare professional responsible for managing and organizing patient medical records to ensure their accuracy, completeness, and security. They play a crucial role in the healthcare system by ensuring that patient information is properly documented, maintained, and accessible to authorized personnel. This includes coding and categorizing patient data, entering it into electronic health record (EHR) systems, and ensuring compliance with regulatory standards. Medical Records Specialists must also maintain patient confidentiality and adhere to privacy laws, such as HIPAA, while facilitating the timely access to data for healthcare providers. Their work supports clinical care, helps with billing and insurance claims, and contributes to the overall efficiency and effectiveness of healthcare services.
Tasks
- Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
- Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
- Consult classification manuals to locate information about disease processes.
- 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.
Technology Skills
- Medical software
- Desktop communications software
- Data base user interface and query software
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Document management software
- Hyland OnBase Platform
- GE Healthcare Centricity Practice Solution
- SoftMed ChartLocater
- SoftMed ChartReserve
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Categorization or classification software
- 3M™ 360 Encompass™ System
- AMA CPT® Coding
- Computerized indexing systems
- 3M™ APR DRG Software
Tools Used
- Microfiche or microfilm viewer components or accessories
- Bar code reader equipment
- Scanners
- Medical paper charting systems
- Magnetic stripe readers and encoders
Detailed Work Activities
- Perform clerical work in medical settings.
- Process healthcare paperwork.
- Classify materials according to standard systems.
- Code data or other information.
- Collect medical information from patients, family members, or other medical professionals.
Work Interests
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Conventional
Work involves following procedures and regulations to organize information or data, typically in a business setting. Conventional occupations are often associated with office work, accounting, mathematics/statistics, information technology, finance, or human resources.
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Investigative
Work involves studying and researching non-living objects, living organisms, disease or other forms of impairment, or human behavior. Investigative occupations are often associated with physical, life, medical, or social sciences, and can be found in the fields of humanities, mathematics/statistics, information technology, or health care service.
Job Outlook
Projected salary and job growth
$35080.0 - $77810.0
This career will grow rapidly in the next few years.
Assessment
Related assessments and tests
No assessment available.