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.

Other names for Medical Records and Health Information Technicians: Administrative Support Assistant, Bill Pay Clerk, Certified Coding Specialist, Certified Medical Coder, Certified Professional Coder (CPC), Clerk, Clinical Analyst, Clinical Data Manager, Clinical Data Specialist, Clinical Office Technician, Clinical Secretary, Coder, Compliance Coordinator, Disability Rater, Document Control Specialist, File Clerk, Filer, Health Information Administrator, Health Information Clerk, Health Information Coder, Health Information Management Clerk, Health Information Management Specialist, Health Information Management Technician, Health Information Specialist, Health Information Systems Technician, Health Record Technician, Health Unit Clerk, Hipaa Compliance Officer, Historian, Hospital Unit Clerk, ICD-9 Coder (International Classification of Diseases Coder), Insurance Coder, Library Historian, Medical Administrative Specialist, Medical Administrative Technician, Medical Biller Coder, Medical Billing and Coding Specialist, Medical Billing Coder, Medical Billing Specialist, Medical Care Evaluation Specialist, Medical Claims Processor, Medical Clerk, Medical Coding Technician, Medical Insurance Coder, Medical Office Technician, Medical Record Assistant, Medical Record Coder, Medical Record Consultant, Medical Record Specialist, Medical Records Analyst, Medical Records Clerk, Medical Records Coordinator, Medical Records Custodian, Medical Records Director, Medical Records Manager, Medical Records Technician, Medical Reimbursement Specialist, Medical Secretary, Medical Transcriptionist, Office Manager, Public Health Registrar, Receptionist, Registered Health Information Technician (RHIT), Release of Information Specialist, Severity of Illness Coordinator, Tumor Registrar,

• Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, or other users.
• Consult classification manuals to locate information about disease processes.
• Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
• Develop in-service educational materials.
• Protect the security of medical records to ensure that confidentiality is maintained.
• Process patient admission and 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 and treatment into computer.
• Release information to persons and agencies according to regulations.
• Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
• Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department.
• Transcribe medical reports.
• Identify, compile, abstract and code patient data, using standard classification systems.
• Resolve or clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.
• Train medical records staff.
• Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
• Post medical insurance billings.
• Process and prepare business and government forms.
• 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.

• Calculators or accessories
• Medical charting systems components or accessories
• Bar code reader equipment
• Electronic funds transfer point of sale equipment
• Desktop computers
• Dictation machines
• Encoder decoder equipment
• Facsimile machines
• Scanners
• Compact disc CD or labeling printers
• Laser printers
• Light stylus
• Microfiche or microfilm viewer components or accessories
• Microfiche or microfilm viewer components or accessories
• Special purpose telephones
• Notebook computers
• Optical character recognition systems
• Personal computers
• Postal scales
• Scanners
• Paper shredding machines or accessories
• Premise branch exchange PBX systems
• Tablet computers
• Touch screen monitors
• Typewriters

Expert system software

Office suite software

Accounting software

Graphics or photo imaging software

Word processing software

Presentation software

Calendar and scheduling software

Spreadsheet software

Optical character reader OCR or scanning software

Document management software

Categorization or classification software

Data base reporting software

Data base user interface and query software

Information retrieval or search software

Medical software

Internet browser software

Transaction security and virus protection software

Voice recognition software

Electronic mail software