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.

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Personality Type

  • Conventional / Enterprising

Knowledge

  • Clinical coding

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

  • 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).

  • Medical terminology

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

  • Professional documentation in health care

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

Skills

  • Review patient's medical data

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

  • Communicate effectively in healthcare

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

  • Maintain healthcare user data confidentiality

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

  • 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.

  • Use electronic health records management system

    Be able to 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.

Optional knowledge and skills

health care system medical informatics collect statistics on medical records human anatomy collect healthcare user's general data identify patients' medical records health records management archive healthcare users' records human physiology