Medical Records Specialist 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 healthcare system. Classify medical and healthcare concepts, including diagnosis, procedures, medical services, and equipment, into the healthcare industry's numerical coding system. Includes medical coders.
Medical Records Specialist is Also Know as
In different settings, Medical Records Specialist is titled as
- Coder
- Health Information Clerk
- Health Information Specialist
- Health Information Technician (Health Information Tech)
- Medical Records Clerk
- Medical Records Coordinator
- Medical Records Technician (Medical Records Tech)
- Registered Health Information Technician (RHIT)
Education and Training of Medical Records Specialist
Medical Records Specialist is categorized in Job Zone Three: Medium Preparation Needed
Experience Required for Medical Records Specialist
Previous work-related skill, knowledge, or experience is required for these occupations. For example, an electrician must have completed three or four years of apprenticeship or several years of vocational training, and often must have passed a licensing exam, in order to perform the job.
Education Required for Medical Records Specialist
Most occupations in this zone require training in vocational schools, related on-the-job experience, or an associate's degree.
Degrees Related to Medical Records Specialist
- Bachelor in Health Information/Medical Records Administration/
- Associate Degree Courses in Health Information/Medical Records Administration/
- Masters Degree Courses in Health Information/Medical Records Administration/
- Bachelor in Health Information/Medical Records Technology/Tech
- Associate Degree Courses in Health Information/Medical Records Technology/Tech
- Masters Degree Courses in Health Information/Medical Records Technology/Tech
- Bachelor in Medical Insurance Coding Specialist/Coder
- Associate Degree Courses in Medical Insurance Coding Specialist/Coder
- Masters Degree Courses in Medical Insurance Coding Specialist/Coder
- Bachelor in Disease Registry Data Management
- Associate Degree Courses in Disease Registry Data Management
- Masters Degree Courses in Disease Registry Data Management
Training Required for Medical Records Specialist
Employees in these occupations usually need one or two years of training involving both on-the-job experience and informal training with experienced workers. A recognized apprenticeship program may be associated with these occupations.
Related Ocuupations
Some Ocuupations related to Medical Records Specialist in different industries are
- Medical Transcriptionists
- Health Information Technologists and Medical Registrars
- Medical Secretaries and Administrative Assistants
- Medical Assistants
- Patient Representatives
- File Clerks
- Document Management Specialists
- Health Informatics Specialists
- Pharmacy Technicians
- Statistical Assistants
- Physician Assistants
- Family Medicine Physicians
- Emergency Medicine Physicians
- Clinical Nurse Specialists
- Management Analysts
- Phlebotomists
- Registered Nurses
- Cardiovascular Technologists and Technicians
- Nurse Practitioners
- Office Clerks, General
What Do Medical Records Specialist do?
- 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.
- Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
- Post medical insurance billings.
- Process and prepare business or government forms.
- Process patient admission or discharge documents.
- Protect the security of medical records to ensure that confidentiality is maintained.
- Release information to persons or agencies according to regulations.
- 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.
- Retrieve patient medical records for physicians, technicians, or other medical personnel.
- Review records for completeness, accuracy, and compliance with regulations.
- Scan patients' health records into electronic formats.
- Schedule medical appointments for patients.
- Transcribe medical reports.
Qualities of Good Medical Records Specialist
Tools Used by Medical Records Specialist
- 10-key calculators
- Barcode attachment equipment
- Barcode scanners
- Credit card processing machines
- Desktop computers
- Dictaphones
- Encoders
- Flat-top scanners
- Label printers
- Laser facsimile machines
- Laser printers
- Light pens
- Microfiche viewing machines
- Microfilm viewing machines
- Multi-line telephone systems
- Notebook computers
- Optical readers and writers
- Paper shredders
- Personal computers
- Postal scales
- Scanners
- Switchboards
- Tablet computers
- Touch screen monitors
Technology Skills required for Medical Records Specialist
- 3M Encoder
- Allscripts EHR
- Amazing Charts
- American Medical Association CodeManager
- Azalea Health Azalea EHR
- Billing software
- Coding database software
- ComChart EMR
- Computerized indexing systems
- Corel WordPerfect Office Suite
- Cyber Records MediChart Express
- Digital Imaging Communications in Medicine DICOM medical imaging software
- DRG grouping software
- e-MDs topsChart
- eClinicalWorks EHR software
- EHS CareRevolution
- Eko
- Electronic medical record EMR software
- Electronic medical record EMR systems
- Email software
- eMDs Practice Partner
- Encoded archival system EAD
- Encoder software
- EndoSoft
- Entity Management Software
- Epic Systems
- Fox Meadows Accent Data Manager
- Fox Meadows ChartingPlus
- Fox Meadows EncounterManager
- GE Healthcare Logician
- Graphics software
- Greenway Medical Technologies PrimeChart
- Health Care Data HealthProbe
- Healthcare common procedure coding system HCPCS
- Henry Schein Dentrix
- HMS
- Holt Systems eMedRec
- Hyland Software OnBase
- IBM Cognos Impromptu
- IBM InfoSphere DataStage
- IBM Lotus 1-2-3
- IBM SPSS Statistics
- IDX Systems IDXtend
- IDX Systems Patient Chart Tracking
- Information Resource Products Clinical Coding Expert
- Laserfiche software
- LeonardoMD Renaissance
- MD Synergy Medical Appointment Scheduling
- Mediasoft mediOFFICE
- Medical condition coding software
- Medical procedure coding software
- MedicWare EMR
- MEDITECH software
- MedStar Systems DrWorks
- Microsoft Access
- Microsoft Dynamics
- Microsoft Excel
- Microsoft Exchange
- Microsoft Office software
- Microsoft Outlook
- Microsoft PowerPoint
- Microsoft Project
- Microsoft SharePoint
- Microsoft SQL Server
- Microsoft SQL Server Reporting Services SSRS
- Microsoft Visio
- Microsoft Visual Basic
- Microsoft Visual Basic Scripting Edition VBScript
- Microsoft Windows
- Microsoft Word
- MicroStrategy
- Minitab
- NCG Medical Systems d-Chart
- NDCMedisoft
- NextGen Healthcare Information Systems EMR
- PCC EHR
- PCC Pediatric Partner
- PowerMed
- Practice Partner Patient Records
- Presentation software
- Purkinje Dossier
- Qlik Tech QlikView
- QMSoftware Receivables Management
- Quest Erwin Data Modeler
- R
- SAP Business Objects
- SAP Crystal Reports
- SAS
- ScanSoft Naturally Speaking
- Scantron imaging software
- Scheduling software
- Siemens Soarian Financials
- Siemens Soarian Scheduling
- SOAPware EMR
- SoftMed ChartLocater
- SoftMed ChartRelease
- SoftMed ChartReserve
- Speech recognition software
- STAT! Systems QD Clinical
- StataCorp Stata
- Structured query language SQL
- SynaMed EMR
- Tableau
- Teradata Database
- VantageMed ChartKeeper
- Virtual private networking VPN software
- Visionary Medical Systems Visionary OFFICE PM
- Voice dictation software
- Web browser software
- Welford Chart Notes
- Word processing software