Profession medical records clerk

Medical records clerks organise, keep up-to-date and archive patients` records for medical staff availability. They transfer medical information from a patient’s paper records to an electronic template.

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Personality Type

  • Conventional / Social

Knowledge

  • Medical informatics

    The processes and tools used for the analysis and dissemination of medical data through computerized systems.

  • Clinical coding

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

  • Professional documentation in health care

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

  • 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).

  • Health care legislation

    The patients` rights and responsibilities of health practitioners and the possible repercussions and prosecutions in relation to medical treatment negligence or malpractice.

  • Health care system

    The structure and function of health care services.

  • Data storage

    The physical and technical concepts of how digital data storage is organised in specific schemes both locally, such as hard-drives and random-access memories (RAM) and remotely, via network, internet or cloud.

  • Database

    The classification of databases, their purpose, terminology, characteristics, models and use such as document-oriented databases, XML databases and full text databases.

  • Administrative tasks in a medical environment

    The medical administrative tasks such as registration of patients, appointment systems, record keeping of patients information and repeated precribing.

  • Medical terminology

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

  • Health records management

    The procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of records.

Skills

  • 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.

  • Process data

    Enter information into a data storage and data retrieval system via processes such as scanning, manual keying or electronic data transfer in order to process large amounts of data.

  • Perform clinical coding procedures

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

  • Collect statistics on medical records

    Perform statistical analysis of various medical records of the healthcare facility, referring to the number of hospital admissions, discharges or waiting lists.

  • Archive healthcare users' records

    Properly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.

  • Display medical problems

    Emphasize significant medical issues in a way that the attention of any healthcare professional using the record is directed on them.

  • Use electronic health records management system

    Be able to use specific software for the management of health care records, following appropriate codes of practice.

  • 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.

  • Perform backups

    Implement backup procedures to backup data and systems to ensure permanent and reliable system operation. Execute data backups in order to secure information by copying and archiving to ensure integrity during system integration and after data loss occurrence.

  • 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.

  • Apply organisational techniques

    Employ a set of organisational techniques and procedures which facilitate the achievement of the set goals set such as detailed planning of personnel's schedules. Use these resources efficiently and sustainably, and show flexibility when required.

  • Comply with quality standards related to healthcare practice

    Apply quality standards related to risk management, safety procedures, patients feedback, screening and medical devices in daily practice, as they are recognized by the national professional associations and authorities.

  • Deliver case notes

    Deliver the appropriate case notes in a timely manner to those requesting them.

  • Work in multidisciplinary health teams

    Participate in the delivery of multidisciplinary health care, and understand the rules and competences of other healthcare related professions.

  • Manage digital archives

    Create and maintain computer archives and databases, incorporating latest developments in electronic information storage technology.

  • Maintain healthcare user data confidentiality

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

  • Type on electronic devices

    Type fast and flawless on electronic devices such as computers in order to ensure a quick and accurate data entry.

  • Collect healthcare user's general data

    Collect qualitative and quantitative data related to the healthcare user's anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests performed by the practitioner.

  • Identify patients' medical records

    Locate, retrieve and present medical records, as requested by authorized medical personnel.

Optional knowledge and skills

answer patients' questions communicate effectively in healthcare pharmacology send biological samples to laboratory review patient's medical data work in a multicultural environment in health care handle paperwork use a computer use communication techniques participate in medical records' auditing activities communicate in foreign languages with health service providers communicate with customers ensure proper appointment administration transfer medical information customer service medical studies

Common job titles

  • File clerk
  • Health information clerk
  • Medical records clerk
  • Medical records clerk full time - kindred hospital medical center
  • Medical records clerk - p/t
  • Medical records – part time
  • Unit clerk - 4 west - per-diem 8-hr, evenings variable shifts