MEDICAL RECORDS TECHNICIAN I

00035

This is responsible clerical work reviewing medical records for accuracy.

Work involves reviewing every document in the medical record for accuracy and for omission of a document. Work also involves the responsibility for contacting a physician for the necessary information or signature on a document. Employees of this class receive detailed instructions in the beginning of employment; however, as experience is gained, employees work with considerable independence. Assistance is available from a medical records librarian if unusual problems are encountered.

Reviews medical records; checks face sheet for procedures performed on patient; checks discharge sheet for discrepancies.

Checks progress notes for missing information; checks discharge progress note for completeness and signatures.

Checks consultation request forms; codes face sheets according to the Standard Nomenclature of Disease and Operations.

Asks physician to restate diagnosis if necessary; notes missing records on deficiency slip.

Assists physicians with simple coding problems and resolution of conflicting diagnoses; codes disease operations; assists in training clerical employees.

Performs related work as required.

Considerable knowledge of the principles of medical records science.

Considerable knowledge of medical terminology and coding systems.

Some knowledge of legal aspects of medical records.

Ability to understand and apply the policies of the hospital and the department.

Ability to use tact and discretion in dealing with physicians and employees.

Ability to become an Accredited Records Technician.

Graduation from a standard high school, supplemented by an approved course for Medical Records Technicians; and some experience in a medical records department; or any equivalent combination of training and experience.