Medical Records Specialists
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.
Sample of reported job titles: 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)
This title represents an occupation for which data collection is currently underway.
Tasks | Technology Skills | Tools Used | Detailed Work Activities | Job Zone | Credentials | Wages & Employment | Job Openings | Additional Information
- 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.
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- Accounting software — Billing software; NDCMedisoft; QMSoftware Receivables Management; Siemens Soarian Financials
- Analytical or scientific software — IBM SPSS Statistics ; Minitab ; SAS ; StataCorp Stata
- Business intelligence and data analysis software — IBM Cognos Impromptu ; MicroStrategy ; Qlik Tech QlikView ; Tableau
- Calendar and scheduling software — MD Synergy Medical Appointment Scheduling; Scheduling software; Siemens Soarian Scheduling
- Categorization or classification software — 3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG grouping software
- Data base management system software — Teradata Database
- Data base reporting software — Microsoft SQL Server Reporting Services ; SAP Crystal Reports ; SoftMed ChartRelease
- Data base user interface and query software — Data entry software; Microsoft Access ; Microsoft SQL Server ; Structured query language SQL (see all 9 examples)
- Desktop communications software — Eko
- Development environment software — Microsoft Visual Basic ; Microsoft Visual Basic Scripting Edition VBScript
- Document management software — Hyland Software OnBase; IDX Systems Patient Chart Tracking; SoftMed ChartLocater; SoftMed ChartReserve (see all 6 examples)
- Electronic mail software — Email software; Microsoft Exchange ; Microsoft Outlook
- Enterprise application integration software — IBM InfoSphere DataStage
- Enterprise resource planning ERP software — Microsoft Dynamics ; SAP Business Objects
- Expert system software — Information Resource Products Clinical Coding Expert
- Graphics or photo imaging software — Graphics software
- Information retrieval or search software — Coding database software
- Internet browser software — Web browser software
- Medical software — Epic Systems ; Healthcare common procedure coding system HCPCS ; Henry Schein Dentrix ; Medical condition coding software (see all 40 examples)
- Metadata management software — CA Erwin Data Modeler
- Network security and virtual private network VPN equipment software — Virtual private networking VPN software
- Object or component oriented development software — R
- Office suite software — Corel WordPerfect; Microsoft Office
- Operating system software — Microsoft Windows
- Optical character reader OCR or scanning software — Scantron imaging software
- Presentation software — Microsoft PowerPoint
- Process mapping and design software — Microsoft Visio
- Project management software — Microsoft Project
- Spreadsheet software — IBM Lotus 1-2-3; Microsoft Excel
- Transaction security and virus protection software — Encoder software
- Voice recognition software — Cyber Records MediChart Express; ScanSoft Naturally Speaking; Speech recognition software; Voice dictation software
- Word processing software — Microsoft Word
Hot Technology — a technology requirement frequently included in employer job postings.
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Detailed Work Activities
- Perform clerical work in medical settings.
- Process healthcare paperwork.
- Classify materials according to standard systems.
- Code data or other information.
- Collect medical information from patients, family members, or other medical professionals.
- Communicate with management or other staff to resolve problems.
- Enter patient or treatment data into computers.
- Maintain medical facility records.
- Maintain medical or professional knowledge.
- Maintain security.
- Monitor medical facility activities to ensure adherence to standards or regulations.
- Prepare official health documents or records.
- Process medical billing information.
- Record patient medical histories.
- Schedule appointments.
- Schedule patient procedures or appointments.
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|Title||Job Zone Three: Medium Preparation Needed|
|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.|
|Job Training||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.|
|Job Zone Examples||These occupations usually involve using communication and organizational skills to coordinate, supervise, manage, or train others to accomplish goals. Examples include hydroelectric production managers, travel guides, electricians, agricultural technicians, barbers, court reporters, and medical assistants.|
|SVP Range||(6.0 to < 7.0)|
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Wages & Employment Trends
Median wage data for Medical Dosimetrists, Medical Records Specialists, and Health Technologists and Technicians, All Other.
Employment data for Medical Dosimetrists, Medical Records Specialists, and Health Technologists and Technicians, All Other.
Industry data for Medical Dosimetrists, Medical Records Specialists, and Health Technologists and Technicians, All Other.
|Median wages (2020)||$21.20 hourly, $44,090 annual|
|Employment (2020)||335,000 employees|
|Projected growth (2020-2030)||Average (5% to 10%)|
|Projected job openings (2020-2030)||27,400|
|Top industries (2020)||
Health Care and Social Assistance
Source: Bureau of Labor Statistics 2020 wage data and 2020-2030 employment projections . “Projected growth” represents the estimated change in total employment over the projections period (2020-2030). “Projected job openings” represent openings due to growth and replacement.
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Job Openings on the Web
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Sources of Additional Information
Disclaimer: Sources are listed to provide additional information on related jobs, specialties, and/or industries. Links to non-DOL Internet sites are provided for your convenience and do not constitute an endorsement.
- American Health Information Management Association
- Medical Billing and Coding
- National Cancer Registrars Association
- National Healthcareer Association
- Occupational Outlook Handbook: Medical records and health information specialists
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