Profession clinical coder

Clinical coders read patients' medical records. They analyse and interpret medical statements about diseases, injuries and procedures. Clinical coders convert this information into health classification codes in order to calculate treatment reimbursements, to produce statistics and to monitor health care performance.

Personality Type

• Conventional / Enterprising

Knowledge

• Professional documentation in health care

  The written standards applied in the health care professional environments for documentation purposes of one`s activity.

• Medical terminology

  The meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.

• Document management

  The methodology of tracking, managing and storing documents in a systematic and organised manner as well as keeping a record of the versions created and modified by specific users (history tracking).

• Clinical coding

  The matching of clinical statements with standard codes of illnesses and treatments through use of a classification system.

Skills

• Maintain healthcare user data confidentiality

  Comply with and maintain the confidentiality of healthcare users` illness and treatment information.

• Communicate effectively in healthcare

  Communicate effectively with patients, families and other caregivers, health care professionals, and community partners.

• Review patient's medical data

  Assess and review relevant medical data of patients such as X-rays, medical history and laboratory reports.

• Use electronic health records management system

  Use specific software for the management of health care records, following appropriate codes of practice.

• Perform clinical coding procedures

  Match and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.

• Follow clinical guidelines

  Follow agreed protocols and guidelines in support of healthcare practice which are provided by healthcare institutions, professional associations, or authorities and also scientific organisations.

• Adhere to organisational guidelines

  Adhere to organisational or department specific standards and guidelines. Understand the motives of the organisation and the common agreements and act accordingly.

• Manage healthcare users' data

  Keep accurate client records which also satisfy legal and professional standards and ethical obligations in order to facilitate client management, ensuring that all clients' data (including verbal, written and electronic) are treated confidentially.

Optional knowledge and skills

Source: Sisyphus ODB