Medical Records Clerk

Medical Records Clerk

Positions in this job family are assigned responsibilities related to preparing, classifying and abstracting medical reports in the medical records unit.

Reviews medical records for completeness and accuracy and refers incomplete or inaccurate reports to appropriate staff for correction.

Prepares statistical, case and other types of reports.

Prepares materials and forms and gathers all pertinent information and data for admissions and discharges.

Ensures all data is properly coded.

Abstracts charts and other patient data in order to respond to requests for information on patients; may make determinations on what materials can legally be released.

Assists in the development of medical records policies and procedures.

Reviews existing policies and procedures to ensure they are in compliance with federal and state laws and agency rules, regulations and policies.

Insures the security and confidentiality of patient medical records.

May supply requested information to courts and other judicial inquiries.

This is the career level where incumbents prepare, classify and abstract medical records, performing assigned duties at the full performance level.

Knowledge, skills and abilities required at this level include knowledge of methods and techniques of medical records maintenance; of applicable federal and state laws and agency and facility policies and procedures; of current classification systems; of report writing techniques; and of medical terminology.

Ability is required to maintain medical records; to code data to records; to review medical records for completeness and accuracy; to prepare reports; to abstract information from records and other patient data; to present information effectively; to establish and maintain effective working relationships with others; and to utilize personal computers.

Education and experience requirements at this level consist of eligibility for accreditation with the American Health Information Management Association as a Registered Health Information Technician (RHIT); or two years of experience working with patient records in a medical setting such as a hospital, state institution, medical clinic or a physician's office.

Based upon the duties and responsibilities assigned to the position being filled, a user agency may require accreditation with the American Health Information Management Association as a Registered Health Technician (RHIT); or eligibility for registration as a Registered Health Information Administrator (RHIA).

Some agencies may have determined positions in this job family to be safety sensitive as defined by 63 O.S. 427.8.