Medical Records

• Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
• Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
• Consult classification manuals to locate information about disease processes.
• Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
• Identify, compile, abstract, and code patient data, using standard classification systems.
• Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
• Post medical insurance billings.
• Process and prepare business or government forms.
• Process patient admission or discharge documents.
• Protect the security of medical records to ensure that confidentiality is maintained.

• Perform clerical work in medical settings.
• Process healthcare paperwork.
• Classify materials according to standard systems.
• Code data or other information.
• Collect medical information from patients, family members, or other medical professionals.
• Communicate with management or other staff to resolve problems.
• Enter patient or treatment data into computers.
• Maintain medical facility records.
• Maintain medical or professional knowledge.
• Maintain security.

• Microfiche or microfilm viewer components or accessories
• Bar code reader equipment
• Scanners
• Medical paper charting systems
• Magnetic stripe readers and encoders
• Paper shredding machines or accessories
• Compact disc CD or labeling printers
• Premise branch exchange PBX systems
• Dictation machines
• Special purpose telephones
• Light stylus
• Optical character recognition systems
• Laser fax machine
• Encoder decoder equipment
• Desktop calculator
• Postal scales
• Notebook computers
• Touch screen monitors
• Laser printers
• Desktop computers
• Personal computers
• Tablet computers

AAPC
American Health Information Management Association
Medical Billing and Coding
National Cancer Registrars Association
National Healthcareer Association
Occupational Outlook Handbook: Medical records and health information specialists

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**TO DO**