Medical Records and Health Information Technicians Go Back to List 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 in a manner consistent with the healthcare industry's numerical coding system.

Tasks
	Protect the security of medical records to ensure that confidentiality is maintained.
	Process patient admission or discharge documents.
	Review records for completeness, accuracy, and compliance with regulations.
	Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
	Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
	Release information to persons or agencies according to regulations.
	Plan, develop, maintain, or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
	Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department.
	Transcribe medical reports.
	Identify, compile, abstract, and code patient data, using standard classification systems.

Skills
	Reading Comprehension - Understanding written sentences and paragraphs in work related documents.
	Active Listening - Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
	Writing - Communicating effectively in writing as appropriate for the needs of the audience.
	Speaking - Talking to others to convey information effectively.
	Critical Thinking - Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
	Monitoring - Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.
	Judgment and Decision Making - Considering the relative costs and benefits of potential actions to choose the most appropriate one.
	Time Management - Managing one's own time and the time of others.
	Social Perceptiveness - Being aware of others' reactions and understanding why they react as they do.
	Complex Problem Solving - Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

Knowledge
	Clerical - Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology.
	English Language - Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
	Computers and Electronics - Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
	Customer and Personal Service - Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
	Administration and Management - Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources.
	Public Safety and Security - Knowledge of relevant equipment, policies, procedures, and strategies to promote effective local, state, or national security operations for the protection of people, data, property, and institutions.
	Medicine and Dentistry - Knowledge of the information and techniques needed to diagnose and treat human injuries, diseases, and deformities. This includes symptoms, treatment alternatives, drug properties and interactions, and preventive health-care measures.
	Education and Training - Knowledge of principles and methods for curriculum and training design, teaching and instruction for individuals and groups, and the measurement of training effects.
	Law and Government - Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.
	Communications and Media - Knowledge of media production, communication, and dissemination techniques and methods. This includes alternative ways to inform and entertain via written, oral, and visual media.

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Education & Training   Education:   Most occupations in this zone require training in vocational schools, related on-the-job experience, or an associate's degree.   Related Experience:   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.

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