Medical Records Specialists

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

Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.

Scan patients' health records into electronic formats.

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

Schedule medical appointments for patients.

Process patient admission or discharge documents.

Post medical insurance billings.

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

Identify, compile, abstract, and code patient data, using standard classification systems.

Consult classification manuals to locate information about disease processes.

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

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

Release information to persons or agencies according to regulations.

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.

Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.

Process and prepare business or government forms.