Medical records clerk

A medical records clerk

Description

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.

Excludes people providing treatment or assistance to patients.

The duties of a medical records clerk include, but are not limited to:

  • Gathering patient demographic and personal information.
  • Issuing medical files to persons and agencies according to laws and regulations.
  • Helping with departmental audits and investigations.
  • Distributing medical charts to the appropriate departments of the hospital.
  • Maintaining quality and accurate records by following hospital procedures.
  • Ensuring patient charts, paperwork, and reports are completed in an accurate and timely manner.
  • Ensuring that all medical records are protected and kept confidential.
  • Filing all patients’ medical records and information.
  • Supplying the nursing department with the appropriate documents and forms.
  • Completing clerical duties, including answering phones, responding to emails, and processing patient admission and discharge records.

Other titles

The following job titles also refer to medical records clerk:

medical note summariser
patients records assistant
clerical officer
health records clerk
clinical records administrator
medical records staff member
health records staff member
medical records assistant
medical records officer
medical records filing clerk
health records assistant

Working conditions

There are a wide variety of work environments that a medical records clerk may operate in. Most of them work in medical offices, sometimes with a team of medical records clerks, sorting through and handling various health records and files each day. They may work primarily on a computer, storing and organizing documents using various systems and folders. 

Others may work more closely with patients and other medical professionals to gather patient information and paperwork. There are also medical records clerks who operate in a more fast-paced hospital setting, where they must quickly file or retrieve important medical history for a patient. 

Minimum qualifications

Medical records clerks are required to have a lot of medical expertise, so applicants should typically have some post-secondary education. Iin some cases, a high school diploma may be enough if the candidate has a relevant work experience. Most employers look for candidates who have at least completed an associate degree or a similarly accredited program in health information technology. Some of the courses applicants should have taken include anatomy, data systems, physiology, coding systems and health care reimbursement.

Medical record clerks are often required to have prior experience in a medical facility. The experience can be obtained through entry-level office jobs, internships or volunteer work. Most employers prefer candidates who have at least 1-2 years of experience in a medical office setting, and some also look for individuals who have experience using computers and data entry software.

ISCO skill level

ISCO skill level is defined as a function of the complexity and range of tasks and duties to be performed in an occupation. It is measured on a scale from 1 to 4, with 1 the lowest level and 4 the highest, by considering:

  • the nature of the work performed in an occupation in relation to the characteristic tasks and duties
  • the level of formal education required for competent performance of the tasks and duties involved and
  • the amount of informal on-the-job training and/or previous experience in a related occupation required for competent performance of these tasks and duties.

Medical records clerk is a Skill level 3 occupation.

Medical records clerk career path

Similar occupations

These occupations, although different, require a lot of knowledge and skills similar to medical records clerk.

clinical coder
medical transcriptionist
medical records manager
chiropractic assistant
waiting list coordinator

Long term prospects

These occupations require some skills and knowledge of medical records clerk. They also require other skills and knowledge, but at a higher ISCO skill level, meaning these occupations are accessible from a position of medical records clerk with a significant experience and/or extensive training.

clinical informatics manager
podiatry assistant
orthoptist
specialist pharmacist
specialist biomedical scientist

Essential knowledge and skills

Essential knowledge

This knowledge should be acquired through learning to fulfill the role of medical records clerk.

  • 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.
  • Medical terminology: The meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.
  • Database: The classification of databases, that includes their purpose, characteristics, terminology, models and use such as XML databases, document-oriented 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 prescribing.
  • 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.
  • Professional documentation in health care: The written standards applied in the health care professional environments for documentation purposes of one`s activity.
  • 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.
  • 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.
  • 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).

Essential skills and competences

These skills are necessary for the role of medical records clerk.

  • Deliver case notes: Deliver the appropriate case notes in a timely manner to those requesting them.
  • Display medical problems: Emphasize significant medical issues in a way that the attention of any healthcare professional using the record is directed on them.
  • 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.
  • 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.
  • Maintain healthcare user data confidentiality: Comply with and maintain the confidentiality of healthcare users` illness and treatment information.
  • Use electronic health records management system: 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.
  • 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.
  • 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.
  • Identify patients’ medical records: Locate, retrieve and present medical records, as requested by authorized medical personnel.
  • 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.
  • 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.
  • 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.
  • Type on electronic devices: Type fast and flawless on electronic devices such as computers in order to ensure a quick and accurate data entry.
  • Apply organisational techniques: Employ a set of organisational techniques and procedures which facilitate the achievement of the goals set. Use these resources efficiently and sustainably, and show flexibility when required.
  • Work in multidisciplinary health teams: Participate in the delivery of multidisciplinary health care, and understand the rules and competences of other healthcare related professions.
  • Perform clinical coding procedures: Match and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.
  • 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.
  • Manage digital archives: Create and maintain computer archives and databases, incorporating latest developments in electronic information storage technology.

Optional knowledge and skills

Optional knowledge

This knowledge is sometimes, but not always, required for the role of medical records clerk. However, mastering this knowledge allows you to have more opportunities for career development.

  • Customer service: Processes and principles related to the customer, client, service user and to personal services; these may include procedures to evaluate customer’s or service user’s satisfaction.
  • Medical studies: The basics and terminology of medical studies.
  • Pharmacology: Pharmacology is a medical specialty mentioned in the EU Directive 2005/36/EC.

Optional skills and competences

These skills and competences are sometimes, but not always, required for the role of medical records clerk. However, mastering these skills and competences allows you to have more opportunities for career development.

ISCO group and title

3252 – Medical records and health information technicians


References
  1. Medical records clerk – ESCO
  2. Medical Records Clerk Job Description – Indeed.com
  3. Medical Records Clerk Job Description – Betterteam
  4. Medical Records Clerk | healthcaresupport.com
  5. Featured image: Photo by Sora Shimazaki from Pexels
Last updated on January 23, 2023

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