Medical Records Technician

SUMMARY. Serves as a medical records technician to process and maintain inpatient, outpatient or ambulatory procedure unit medical records. Required to compile, extract or locate medical information/data to ensure medical record accountability and availability in accordance with DoD and medical service standards.

1. QUALIFICATIONS:

1.1. Mandatory knowledge and skills.

1.1.1. A fully qualified typist (computer keyboard) with a minimum of 40 WPM is required.

1.1.2. English language, correct grammar, spelling, punctuation, capitalization, and format to prepare and edit written correspondence, reports, and transcribed material.

1.1.3. Standard office equipment, such as computers, typewriters, copiers, fax machines, telephone systems and office automation systems, to perform a substantial range of medical record maintenance support.

1.1.4. General medical ethics, telephone etiquette, and excellent communication and customer service skills.

1.1.5. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for complete, prompt, and accurate health records.

1.2. Education. High School diploma or General Educational Development (GED) equivalency. Basic medical terminology required.

1.3. Experience. At least one year relevant experience or specialized Registered Health Information Technician (RHIT) or Registered Health Information Administrator certification required.

1.4. Work Environment/Physical Requirements. Requirements include prolonged walking, standing, sitting or bending. Must be able to carry 25-50 pounds and reach high shelving units with the assistance of stepladders to retrieve and file medical records.

2. UNIQUE MILITARY HEALTH CARE SYSTEMS/PROCEDURES:

2.1. Armed Forces Health Longitudinal Technology Application (AHLTA)

2.2. Composite Health Care systems (CHCS) and/or MHS GENESIS

2.3. Defense Enrollment Eligibility Reporting System (DEERS);

2.4. Military Filing System - by sponsor social security number, terminal digit order, color-coded and blocked filing system.

2.5. Contents of a military medical record, layout, sections, family member prefix designation, forms used in a MTF, and the medical record tracking procedures.

2.6 Health Artifact and Management Solutions (HAIMS)

3. PERFORMANCE OUTCOMES:

3.1. Initiates and maintains medical records in accordance with prescribed directives.

3.2. Files military forms documenting patient care into patient medical records.

3.3. Conducts daily pull, delivery and retrieval of patient records.

3.4. Searches for missing paperwork or records. Requests information pertaining to patient treatment to place in the medical record.

3.5. Prepares reports regarding record statistics as necessary. Participates in records review as part of

the

facility’s quality assurance program and in accordance with accreditation standards.

3.6. Reviews records to ensure proper and complete documentation.

3.7. Retires medical records in accordance with regulatory guidelines.