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Medical Records and Health Information Technicians - 29-2071.00

O*NET-SOC Description

Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system.

Sample of Reported Job Titles

  • Coder
  • Health Information Clerk
  • Health Information Specialist
  • Health Information Technician (Health Information Tech)
  • Medical Records Analyst
  • Medical Records Clerk
  • Medical Records Coordinator
  • Medical Records Director
  • Medical Records Technician (Medical Records Tech)
  • Registered Health Information Technician (RHIT)

SOC Occupation Groups

Related Occupations

Tasks

  • Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  • Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
  • Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
  • Consult classification manuals to locate information about disease processes.
  • Develop in-service educational materials.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Identify, compile, abstract, and code patient data, using standard classification systems.
  • Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department.
  • Plan, develop, maintain, or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
  • Post medical insurance billings.
  • Prepare statistical reports, narrative reports, or graphic presentations of information, such as tumor registry data for use by hospital staff, researchers, or other users.
  • Process and prepare business or government forms.
  • Process patient admission or discharge documents.
  • Protect the security of medical records to ensure that confidentiality is maintained.
  • Release information to persons or agencies according to regulations.
  • 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.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.
  • Review records for completeness, accuracy, and compliance with regulations.
  • Train medical records staff.
  • Transcribe medical reports.

Detailed Work Activities

  • Enter patient or treatment data into computers.
  • Maintain medical facility records.
  • Maintain medical or professional knowledge.
  • Manage healthcare operations.
  • Monitor medical facility activities to ensure adherence to standards or regulations.
  • Perform clerical work in medical settings.
  • Prepare healthcare training materials.
  • Prepare official health documents or records.
  • Present medical research reports.
  • Process healthcare paperwork.
  • Process medical billing information.
  • Record patient medical histories.
  • Supervise medical support personnel.
  • Train caregivers or other non-medical personnel.

Military Crosswalk Titles

  • Health Services Management Apprentice (Air Force - Enlisted)
  • Health Services Management Craftsman (Air Force - Enlisted)
  • Health Services Management Helper (Air Force - Enlisted)
  • Health Services Management Journeyman (Air Force - Enlisted)
  • Hospital Corpsman (Navy - Enlisted)
  • Hospital Corpsman Basic (Navy - Enlisted)
  • Medical Department Administrative Assistant (Navy - Enlisted)
  • Patient Administration Specialist (Army - Enlisted)

Apprenticeship Crosswalk Titles

  • Medical Coder
  • Tumor Registrar

DOT Crosswalk Titles

  • Medical Record Coder
  • Medical Record Technician
  • Medical-Record Clerk
  • Public Health Registrar
  • Tumor Registrar