Medical Records Specialists — Tasks

Task statements

• Protect the security of medical records to ensure that confidentiality is maintained.
• Review records for completeness, accuracy, and compliance with regulations.
• Scan patients' health records into electronic formats.
• Release information to persons or agencies according to regulations.
• Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
• Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
• Process patient admission or discharge documents.
• Retrieve patient medical records for physicians, technicians, or other medical personnel.
• 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.
• Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
• Identify, compile, abstract, and code patient data, using standard classification systems.
• Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
• Process and prepare business or government forms.
• Consult classification manuals to locate information about disease processes.
• Transcribe medical reports.
• Schedule medical appointments for patients.