Job Description:

Compile, process, and maintain medical records of hospital and clinic clients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report client information for health requirements and standards.

Job Responsibilities & Performance Standards:

Compiles and maintains clients’ medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts
Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer
Identifies, compiles, abstracts and codes client data, using standard classification systems
Plans, develops, maintains and operates a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information
Processes client admission and discharge documents
Protects the security of medical records to ensure that confidentiality is maintained
Releases information to persons and agencies according to regulations
Reviews records for completeness, accuracy and compliance with regulations
Transcribes medical reports