MEDICAL RECORDS TECHNICIAN 32111

02/16/90 C

This is the first class in the Medical Records series for classes that are responsible for processing, maintaining, compiling, and reporting health information using medical records and other medical data in a variety of agencies or institutions. Positions assigned to this class work in a medical environment which may be a large, self-contained medical or treatment complex; or in a subordinate unit of an organization whose primary focus is other than medical care. Duties are of a generalist nature except in large medical facilities where partial or total specialization is required. This class is distinguished from the Medical Records Technician Senior class by the latter's lead worker or charge responsibilities and wider range/complexity of duties.

Complexity of Work: Performs work of routine difficulty which involves reviewing, coding, abstracting, delivering, retrieving, filing and storing medical records. Evaluates files for correctness and completeness; analyzes health records according to standards; codes according to standardized classification systems for purposes of temporary or long-term storage and for use in developing statistical reports and tabulating data; and abstracts files in various formats such as sequence or intervals and provides to users for purposes of case study, statistical reports, and tracking of individual patients or groups of patients. Identifies and determines data elements to be entered into computer systems. Provides technical advice to hospital personnel and other state medical records technicians regarding compliance with reporting demographic and clinical data; and advises of errors. Positions may also respond to internal and external requests for information from those files. May disburse or retrieve files to and from short-term users; may be responsible for long-term storage of inactive files; and/or may perform some clerical duties related to the maintenance/establishment of files. May be required to seek assistance from manuals or higher level positions for resolution of more difficult or unusual tasks. Refers incorrect or incomplete files to higher level personnel or originator for correction or completion. May specialize in illness-specific files or one or more of the functions described above.

Supervision Given: Supervision is typically not a factor.

Supervision Received: Receives immediate supervision from a Medical Records Supervisor, Medical Records Manager, higher level administrative position, or from a medical or nursing staff position.

Scope: Work affects the accuracy and maintenance of medical records which are used by various departments of the agency.

Impact of Actions: Data errors, omissions,or misplaced/lost files can negatively impact the diagnostic, treatment research, education, administrative decisions, reimbursement, and litigation involving the patient, physician and facility which are based on the information provided in the medical records. Effective job performance ensures the accurate provision of file information and in efficient filing operations.

Personal Contacts: Frequent internal contacts with agency staff in the provision and retrieval of files and information. Infrequent external contact with various information seekers. Frequent internal and external contacts with hospital personnel, other state medical records technicians, program coordinators and registrars to provide information.

Knowledges: Some knowledge of the rules and regulations governing the preparation and maintenance of medical records; of standard medical and surgical terminology; of medical information management and medical coding; of disease processes; of uniform data definitions; and of disease classification systems.

Skills: Working skill in the use of a computer keyboard may be required.

Abilities: Demonstrated ability to arrange, track, or extract detailed information; to understand medical and surgical terminology and diseases processes; and to comprehend and communicate effectively.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

Education or Training: Graduation from high school or equivalent and completion of an approved program of instruction for medical records technician.

Level and Type of Experience: None identified for entrance into this class.

An equivalent combination of training and experience indicating possession of the preceding knowledges and abilities may substitute for this education and experience.

This class was revised as a result of the statewide Classification Review/Specification Update Program, effective February 1990.