Medical Records

Job Title: Medical Records/Health Information Technician

Department: Medical Records, Health Information

Immediate Supervisor Title: Clinic Administrator

Job Supervisory Responsibilities: None

General Summary: A nonexempt position responsible for assembling patient information into patients’ medical charts/records in accurate and complete manner. Position responsibilities vary by size of medical practice and type of technology used such as electronic medical records versus manual files.

Essential Job Responsibilities:

1. Assembles patients’ health information including patient symptoms and medical history, exam results, X-ray reports, lab tests, diagnoses, and treatment plans. Checks to ensure all forms are completed, properly identified, and signed and that all necessary information is in the manual and/or computer file in preferred manner such as chronological. 
2. Communicates as needed with physicians and other health care professionals to clarify diagnoses or to obtain additional information.
3. Submits files/documentation to physicians and other clinicians as requested for review, quality assurance checks, and other purposes.
4. Indexes patients’ information/correspondence in the appropriate section of electronic records. 
5. Other duties as assigned.

Education: High school diploma. Knowledge of medical office procedures and HIPAA regulations.

Experience: Minimum two years of medical records clerk/health information technician experience, preferably in medical practice setting.

Other Requirements: Good reading skills and ability to follow alphabetic or numeric filing systems.

Performance Requirements:

Knowledge:

1. Knowledge of biology, chemistry, health, and computer science.
2. Knowledge of medical terminology.
3. Knowledge of legal and ethical considerations related to patient information.

Skills:

1. Skill in putting information in preferred medical record system, meeting clinic standards.
2. Skill in dealing with masses of information in organized manner.
3. Skill in using computer and medical records software.

Abilities:

1. Ability to alphabetize and put information (materials, forms, etc.) into chronological order.
2. Ability to analyze medical records for completeness and accuracy, paying attention to detail.
3. Ability to schedule time and assignments effectively.

Equipment Operated: Range of medical records equipment and supplies, including computer hardware/software, manual files, and sorters.

Work Environment: Usually pleasant and comfortable offices. Little contact with patients. 

Mental/Physical Requirements: Combination of standing, sitting, bending, and reaching. May work at computer monitors for prolonged periods with danger of eye strain and muscle pain. Stress generated if workload is heavy.