Medical Records Tech

Medical Records Technician

SUMMARY. Serves as a medical records technician to process and maintain inpatient, outpatient or ambulatory procedure unit medical records. Required to compile or extract medical records data to ensure compliance with regulatory requirements.

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QUALIFICATIONS.

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Mandatory knowledge and skills.

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A fully qualified typist (computer keyboard) with a minimum of 40 WPM is required.

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English language, correct grammar, spelling, punctuation, capitalization, and format to prepare and edit written correspondence, reports, and transcribed material.

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Standard office equipment, such as computers, typewriters, copiers, fax machines, telephone systems and office automation systems, to perform a substantial range of medical record maintenance support.

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General medical ethics, telephone etiquette, and excellent communication and customer service skills.

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Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for complete, prompt, and accurate health records.

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Unique military health care computer systems/procedures:
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Composite Health Care systems (CHCS) – AHLTA;

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Defense Enrollment Eligibility Reporting System (DEERS);

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Military Filing System – by sponsor social security number, terminal digit order, color-coded and blocked filing system.

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Contents of a military medical record, layout, sections, family member prefix designation, forms used in a MTF, and the medical record tracking procedures are highly desired.

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Education. High School diploma or General Educational Development (GED) equivalency. Basic medical terminology required.

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Experience. At least one year relevant experience or specialized Registered Health Information Technician (RHIT) or Registered Health Information Administrator certification required.

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Work Environment/Physical Requirements. Requirements include prolonged walking, standing, sitting or bending. Must be able to carry 25-50 pounds and reach high shelving units with the assistance of step ladders to retrieve and file medical records.

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SPECIFIC TASKS.

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Initiates and maintains medical records in accordance with prescribed directives.

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Files military forms documenting patient care into patient medical records.

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Conducts daily pull, delivery and retrieval of patient records.

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Searches for missing paperwork or records. Requests information pertaining to patient treatment to place in the medical record.

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Prepares reports regarding record statistics as necessary. Participates in records review as part of the facility’s quality assurance program and in accordance with accreditation standards.

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Reviews records to ensure proper and complete documentation.

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Retires medical records in accordance with Air Force guidelines.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled