Compiles, processes, and maintains medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the heath care system. Processes, maintains, compiles, and reports patient information for health requirements and standards in a manner consistent with the healthcare industry’s numerical coding system.
This career is part of the Health Science cluster Health Informatics pathway.
A person in this career:
- Protects the security of medical records to ensure that confidentiality is maintained.
- Reviews records for completeness, accuracy, and compliance with regulations.
- Retrieves patient medical records for physicians, technicians, or other medical personnel.
- Assigns the patient to diagnosis-related groups (DRGs), using appropriate computer software.
- Processes patient admission or discharge documents.
- Transcribes medical reports.
- Resolves or clarifies 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.
- Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
- Identifies, compiles, abstracts, and codes patient data, using standard classification systems.
- Releases information to persons or agencies according to regulations.
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