Medical Records and Health Information Technicians

Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.

Protect the security of medical records to ensure that confidentiality is maintained.

Review records for completeness, accuracy, and compliance with regulations.

Process patient admission or discharge documents.

Transcribe medical reports.

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.

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.

Retrieve patient medical records for physicians, technicians, or other medical personnel.

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.

Prepare statistical reports, narrative reports, or graphic presentations of information, such as tumor registry data for use by hospital staff, researchers, or other users.

Post medical insurance billings.

Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.

Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department.

Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.

Train medical records staff.

Process and prepare business or government forms.

Consult classification manuals to locate information about disease processes.

Develop in-service educational materials.