Medical Records Clerk Job Description

The medical records clerk job description is very important to healthcare.  Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians organize and evaluate these records for completeness and accuracy.

Technicians assemble patients’ health information. They make sure that patients’ initial medical charts are complete, that all forms are completed and properly identified and signed, and that all necessary information is in the computer. They regularly communicate with physicians and other health care professionals to clarify diagnoses or to obtain additional information.

Medical records clerks and health information technicians’ duties vary with the size of the facility where they work. In large to medium-sized facilities, technicians might specialize in one aspect of health information or might supervise health information clerks and transcriptionists while a medical records and health information administrator manages the department. In small facilities, a credentialed medical records and health information technician sometimes manages the department.

Working Conditions

As part of the medical records clerk job description medical records and health information technicians usually work a 40-hour week. Some overtime may be required. In hospitals—where health information departments often are open 24 hours a day, 7 days a week—technicians may work day, evening, and night shifts.

Medical records and health information technicians work in pleasant and comfortable offices. This is one of the few health occupations in which there is little or no direct contact with patients. Because accuracy is essential in their jobs, technicians must pay close attention to detail. Technicians who work at computer monitors for prolonged periods must guard against eyestrain and muscle pain.

Training and Qualifications - what you have to do to be a Medical Records Clerk

Medical records and health information technicians entering the field usually have an associate degree from a community or junior college. In addition to general education, coursework includes medical terminology, anatomy and physiology, legal aspects of health information, coding and abstraction of data, statistics, database management, quality improvement methods, and computer science. Applicants can improve their chances of admission into a program by taking biology, chemistry, health, and computer science courses in high school.

Licensing and Credentialing

There is no actual licensing requirement although some states may require registration or certification.  Most employers prefer to hire Registered Health Information Technicians (RHIT), who must pass a written examination offered by the American Health Information Management Association (AHIMA). To take the examination, a person must graduate from a 2-year associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). Technicians trained in non-CAHIIM-accredited programs or trained on the job are not eligible to take the examination. In 2005, CAHIIM accredited 184 programs for health information technicians.

Significant Points

Employment is expected to grow much faster than average.

Job prospects should be very good; technicians with a strong background in medical coding will be in particularly high demand.

Entrants usually have an associate degree; courses include anatomy, physiology, medical terminology, statistics, and computer science.

This is one of the few health occupations in which there is little or no direct contact with patients.

Advancement - chances for promotion

Experienced medical records and health information technicians usually advance in one of two ways—by specializing or managing. Many senior technicians specialize in coding, particularly Medicare coding, or in cancer registry. Most coding and registry skills are learned on the job. Some schools offer certificates in coding as part of the associate degree program for health information technicians, although there are no formal degree programs in coding. For cancer registry, there were 11 formal 2-year certificate programs in 2005 approved by the National Cancer Registrars Association (NCRA). Some schools and employers offer intensive 1- to 2-week training programs in either coding or cancer registry. Once coders and registrars gain some on-the-job experience, many choose to become certified. Certifications in coding are available either from AHIMA or from the American Academy of Professional Coders. Certification in cancer registry is available from the NCRA.

In large medical records and health information departments, experienced technicians may advance to section supervisor, overseeing the work of the coding, correspondence, or discharge sections, for example. Senior technicians with RHIT credentials may become director or assistant director of a medical records and health information department in a small facility. However, in larger institutions, the director usually is an administrator with a bachelor’s degree in medical records and health information administration.