Basic Job Description:
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.
1) Protect the security of medical records to ensure that confidentiality is maintained.
2) Process patient admission and discharge documents.
3) Review records for completeness, accuracy and compliance with regulations.
4) Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
5) Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.
6) Release information to persons and agencies according to regulations.
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7) Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
8) Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department.
9) Transcribe medical reports.
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10) Identify, compile, abstract and code patient data, using standard classification systems.
11) Resolve/clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others to get additional information and by participating in the coding team's regular meetings.
12) Train medical records staff.
13) Assign the patient to one of several hundred "diagnosis-related groups", or DRGs, using appropriate computer software.
14) Post medical insurance billings.
15) Process and prepare business and government forms.
16) Contact discharged patients, their families, and physicians to maintain registry with follow-up information, such as quality of life and length of survival of cancer patients.
17) Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, and other users.
18) Consult classification manuals to locate information about disease processes.
19) Compile medical care and census data for statistical reports on diseases treated, surgery performed, and use of hospital beds.
20) Develop in-service educational materials.
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Holland / RIASEC Career Code: C-R-I SOC: 29-2071.00