Compiles health information (e.g., reviews, catalogs & checks medical reports for completeness; organizes medical reports for placement in files; reviews charts to ensure all reports & signatures are present).
Types health information forms (e.g., prepares charts for new admissions; fills out forms; prepares requests for specific reports or certificates).
Compiles & types statistical reports such as daily & monthly census, Medicaid days, admissions, discharges, or length of stay.
Files reports into health information records, records information in logs & files & retrieves health information records in filing system.
Provides information from health information records after determining appropriateness of request.
Coordinates with other departments concerning health information records procedures.
9 months experience or 3 courses in records management
3 months experience or 1 course in medical terminology
3 months or 1 course experience data entry
Knowledge of health information technology; JCAH & Medicare/Medicaid regulations governing medical record keeping*
Requirements governing confidentiality of patient information*; medical terminology.
Data entry and usage of calculator.
Ability to deal with problems involving few variables within familiar context; write routine business letters, evaluations or records following standard procedures; proofread medical reports & recognize errors; recognize when medical records information is missing; gather collate & classify information about data, people or things.