Medical record technician job description
This post includes 3 parts: duties list, job qualification and job description writing tips for Medical record technician in details. A comp...
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This post includes 3 parts: duties list, job qualification and job description writing tips for Medical record technician in details. A complete job description concludes Medical record technician key duties/responsibilities, Medical record technician job qualifications (knowledge, education, skills, abilities, experience…KSA model) and other ones such as daily tasks, key activities, key/core competencies, job functions/purpose…
I. List of Medical record technician duties:
1. Performs clerical work in support of the care and treatment given to patients upon intake and throughout detention.
2. Assists senior staff by administering the medical records system.
3. Maintains medical records in a clinical setting using manual and/or electronic systems.
4. Appropriately files individual documents and/or other information in medical records.
5. Accurately identifies information contained in records.
6. Assembles medical records ensuring accuracy and compliance with regulatory requirements.
7. Assembles medical records in proper sequence.
8. Ensures all necessary forms and documents are present, accurate, and complete.
9. Requests, initiates and files all health records in terminal digit order adhering to color-coded/electronic system.
10. Attaches and files information in each health record according to IHSC Health Services Policy and Procedure Manual.
11. Obtains provider''s signature on all ordered tests and studies including all outside medical reports.
12. Accurately assigns codes describing each diagnosis, surgical procedure and special therapy or procedure.
13. Uses standard medical record references, i.e., DRG''s.
14. Codes information contained on several forms and documents which make up an entire record.
15. Accurately codes diseases, surgical procedures, and causes of injury.
16. Accurately codes stages of disease using International Classification of Diseases (ICD) for Oncology.
17. Enters patient information into computerized patient information system according to ICD-9-CM.
18. Performs daily computer backup of health computer information system.
19. Responds to requests for copies of health records from detainees and logs all activity in the FOIA (Freedom of Information Act) logbook.
20. Ensures only authorized personnel have access to health records and patient information.
21. Maintains both active and inactive health records in a locked secure environment.
22. Performs other duties as assigned.
23. Follows supervisory chain of command.
II. List of Medical record technician qualifications
1. Must have at least one year of medical records experience.
2. Understand, speak, read, and write English fluently.
3. Knowledge of the basic principles of standard medical record procedures, methods, and requirements to perform a full range of routine medical records management.
4. Knowledge of the procedures, rules, operations, sequence of steps, documentation requirements, time requirements, functions, and workflow to process medical records, to review records for accuracy and completeness, and to keep track of processing deadlines.
5. Knowledge of medical terminology.
6. Knowledge of regulations on the confidentiality of medical records (HIPPA).
7. Ability to manage high volume of medical records daily, to include intake, discharge, and requests for records from outside sources.
8. Experience with electronic medical records is preferred.
III. Tips to write job description
1. Too-long job description:
Looking at a too-long job description can frighten the candidates off and drive the away. A job description, no matter how important the job is, should not be included in more than 3 pages. If one focuses on too many things at a time, he shall definitely lose focus on the main items and get overwhelmed by the remaining; So, keep it concisely.
2. Too-short job description:
While too-long can be a problem, too-short is more a problem. It will ruin the meaning of the job description. A too-short one means it lacks necessary details and therefore, the candidate will not be able to understand while reading it.
3. Listing unnecessary functions or job duties:
Just classifying these into the “others” category will save you a lot of effort and space. On the other hand, the job description will become more dilute and easy to be neglected.
4. Key functions
Not listing key functions as required for the job can be a fatal mistake to a job description.
5. Grammar and spelling
Poor grammar and having spelling errors can ruin the job description, too. Never think that as you are the employer, you may have the right to make grammar or spelling errors while requires other not to. A job description with such errors is easily to be mistaken as a fake or ghost ads; as a result, the candidate will turn away from it.
6. Not specific enough:
Be specific and concise; if you don’t address the specific, then what the job description is for. It is for the candidate to understand just exactly what he needs to do or needs to have. Lacking details can confuse the candidates very well.
7. Not having the job description reviewed by others:
This is also a common mistake. One may be subject to bias, but more than one, especially with the help of those external advisor, the job description can be more perfect.
8. Using buzzwords or abbreviations:
In fact, it is not necessary at all to use such in a job description.
9. Using slang or legal words:
Just use common wording to communicate with others and don’t do anything extraordinarily.
10. Not updating the job description:
The same job may require different duties and responsibilities in different times, so, you cannot use the same job description for 2 different times.
