Summary Report for:
29-2071.00 - Medical Records and Health Information Technicians
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.
Sample of reported job titles:
Medical Records Clerk, Health Information Clerk, Medical Records Technician, Office Manager, File Clerk, Medical Records Coordinator, Medical Records Analyst, Medical Records Director, Receptionist, Coder
Tasks | Tools & Technology | Knowledge | Skills | Abilities | Work Activities | Work Context | Job Zone | Interests | Work Styles | Work Values | Related Occupations | Wages & Employment | Additional Information
Tasks
- Protect the security of medical records to ensure that confidentiality is maintained.
- Review records for completeness, accuracy and compliance with regulations.
- Retrieve patient medical records for physicians, technicians, or other medical personnel.
- 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.
- Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.
- Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
- Process and prepare business and government forms.
- Process patient admission and discharge documents.
- Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
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Tools & Technology
Tools used in this occupation:
| Medical charting systems components or accessories — Barcode attachment equipment |
| Microfiche or microfilm viewer components or accessories — Microfiche viewing machines; Microfilm viewing machines |
| Postal scales |
| Scanners — Flat-top scanners |
| Special purpose telephones — Multi-line telephone systems |
Technology used in this occupation:
| Accounting software — Billing software; NDCMedisoft software; QMSoftware Receivables Management; Siemens Soarian Financials |
| Data base user interface and query software — EAD Systems software; Microsoft Access; O-HEAP software; Purkinje Dossier |
| Document management software — Fox Meadows Accent Data Manager; Hyland Software OnBase; SoftMed ChartLocater; SoftMed ChartReserve |
| Medical software — eClinicalWorks software; Electronic medical record EMR software; Visionary Medical Systems Visionary OFFICE PM; Welford Chart Notes |
| Voice recognition software — Cyber Records MediChart Express; ScanSoft Naturally Speaking; Speech recognition software; Voice dictation software |
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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. |
| 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. |
| 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. |
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Skills
| 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. |
| Monitoring — Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action. |
| Reading Comprehension — Understanding written sentences and paragraphs in work related documents. |
| Critical Thinking — Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. |
| Speaking — Talking to others to convey information effectively. |
| Complex Problem Solving — Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. |
| Coordination — Adjusting actions in relation to others' actions. |
| Time Management — Managing one's own time and the time of others. |
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Abilities
| Near Vision — The ability to see details at close range (within a few feet of the observer). |
| Information Ordering — The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations). |
| Oral Expression — The ability to communicate information and ideas in speaking so others will understand. |
| Problem Sensitivity — The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem. |
| Written Comprehension — The ability to read and understand information and ideas presented in writing. |
| Category Flexibility — The ability to generate or use different sets of rules for combining or grouping things in different ways. |
| Finger Dexterity — The ability to make precisely coordinated movements of the fingers of one or both hands to grasp, manipulate, or assemble very small objects. |
| Speech Clarity — The ability to speak clearly so others can understand you. |
| Speech Recognition — The ability to identify and understand the speech of another person. |
| Deductive Reasoning — The ability to apply general rules to specific problems to produce answers that make sense. |
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Work Activities
| Getting Information — Observing, receiving, and otherwise obtaining information from all relevant sources. |
| Interacting With Computers — Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information. |
| Organizing, Planning, and Prioritizing Work — Developing specific goals and plans to prioritize, organize, and accomplish your work. |
| Establishing and Maintaining Interpersonal Relationships — Developing constructive and cooperative working relationships with others, and maintaining them over time. |
| Evaluating Information to Determine Compliance with Standards — Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards. |
| Communicating with Supervisors, Peers, or Subordinates — Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person. |
| Performing Administrative Activities — Performing day-to-day administrative tasks such as maintaining information files and processing paperwork. |
| Identifying Objects, Actions, and Events — Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events. |
| Documenting/Recording Information — Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form. |
| Processing Information — Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data. |
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Work Context
| Telephone — How often do you have telephone conversations in this job? |
| Importance of Being Exact or Accurate — How important is being very exact or highly accurate in performing this job? |
| Contact With Others — How much does this job require the worker to be in contact with others (face-to-face, by telephone, or otherwise) in order to perform it? |
| Face-to-Face Discussions — How often do you have to have face-to-face discussions with individuals or teams in this job? |
| Indoors, Environmentally Controlled — How often does this job require working indoors in environmentally controlled conditions? |
| Structured versus Unstructured Work — To what extent is this job structured for the worker, rather than allowing the worker to determine tasks, priorities, and goals? |
| Importance of Repeating Same Tasks — How important is repeating the same physical activities (e.g., key entry) or mental activities (e.g., checking entries in a ledger) over and over, without stopping, to performing this job? |
| Work With Work Group or Team — How important is it to work with others in a group or team in this job? |
| Time Pressure — How often does this job require the worker to meet strict deadlines? |
| Freedom to Make Decisions — How much decision making freedom, without supervision, does the job offer? |
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Job Zone
| Title |
Job Zone Two: Some Preparation Needed |
| Overall Experience |
Some previous work-related skill, knowledge, or experience may be helpful in these occupations, but usually is not needed. For example, a teller might benefit from experience working directly with the public, but an inexperienced person could still learn to be a teller with little difficulty. |
| Job Training |
Employees in these occupations need anywhere from a few months to one year of working with experienced employees. |
| Job Zone Examples |
These occupations often involve using your knowledge and skills to help others. Examples include sheet metal workers, forest fire fighters, customer service representatives, pharmacy technicians, salespersons (retail), and tellers. |
| SVP Range |
(4.0 to < 6.0) |
| Education |
These occupations usually require a high school diploma and may require some vocational training or job-related course work. In some cases, an associate's or bachelor's degree could be needed. |
There are 2 recognized apprenticeable specialties associated with this occupation:
Tumor Registrar; Medical Coder
To learn about specific apprenticeship opportunities, please consult the U.S. Department of Labor State Apprenticeship Information
website.
For general information about apprenticeships, training, and partnerships with
business, visit the U.S. Department of Labor Office of Apprenticeship
website.
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Interests
Interest code: CE
| Conventional — Conventional occupations frequently involve following set procedures and routines. These occupations can include working with data and details more than with ideas. Usually there is a clear line of authority to follow. |
| Enterprising — Enterprising occupations frequently involve starting up and carrying out projects. These occupations can involve leading people and making many decisions. Sometimes they require risk taking and often deal with business. |
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Work Styles
| Attention to Detail — Job requires being careful about detail and thorough in completing work tasks. |
| Integrity — Job requires being honest and ethical. |
| Dependability — Job requires being reliable, responsible, and dependable, and fulfilling obligations. |
| Independence — Job requires developing one's own ways of doing things, guiding oneself with little or no supervision, and depending on oneself to get things done. |
| Cooperation — Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude. |
| Adaptability/Flexibility — Job requires being open to change (positive or negative) and to considerable variety in the workplace. |
| Self Control — Job requires maintaining composure, keeping emotions in check, controlling anger, and avoiding aggressive behavior, even in very difficult situations. |
| Concern for Others — Job requires being sensitive to others' needs and feelings and being understanding and helpful on the job. |
| Initiative — Job requires a willingness to take on responsibilities and challenges. |
| Stress Tolerance — Job requires accepting criticism and dealing calmly and effectively with high stress situations. |
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Work Values
| Relationships — Occupations that satisfy this work value allow employees to provide service to others and work with co-workers in a friendly non-competitive environment. Corresponding needs are Co-workers, Moral Values and Social Service. |
| Support — Occupations that satisfy this work value offer supportive management that stands behind employees. Corresponding needs are Company Policies, Supervision: Human Relations and Supervision: Technical. |
| Independence — Occupations that satisfy this work value allow employs to work on their own and make decisions. Corresponding needs are Creativity, Responsibility and Autonomy. |
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Related Occupations
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Wages & Employment Trends
National
| Median wages (2007) |
$14.08 hourly, $29,290 annual |
| Employment (2006) |
170,000 employees |
| Projected growth (2006-2016) |
Faster than average (14% to 20%)
|
| Projected need (2006-2016) |
76,000 additional employees |
State & National
Source: Bureau of Labor Statistics 2007 wage data
and 2006-2016 employment projections
.
"Projected growth" represents the estimated change in total employment over the projections period (2006-2016). "Projected need" represents job openings due to growth and net replacement.
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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.
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