JOB DESCRIPTION
Job Title: Medical Records Clerk / Health Information Technician
General Summary: A nonexempt position responsible for assembling patient
information into patients’ medical charts/records in accurate and complete manner.
Position responsibilities vary by size of medical practice and type of technology used
such as electronic medical records versus manual files.
Immediate Supervisor Title: Medical Records, Health Information, or Clinical Services
Manager
Job Supervisory Responsibilities: None
Essential Job Responsibilities:
1. Assembles patients’ health information including patient symptoms and medical
history, exam results, X-ray reports, lab tests, diagnoses, and treatment plans.
Checks to ensure all forms are completed, properly identified, and signed and that
all necessary information is in the manual and/or computer file in preferred
manner such as chronological.
2. Communicates as needed with physicians and other health care professionals to
clarify diagnoses or to obtain additional information.
3. Submits files/documentation to physicians and other clinicians as requested for
review, quality assurance checks, and other purposes.
4. Provides charts/documents requested for use in legal actions, following patient
consent/confidentiality protocols.
5. Codes patients’ information periodically (as back-up) for insurance purposes.
Assigns a code to each diagnosis and procedure (diagnosis-related group [DRG]).
6. Uses computer programs if requested to tabulate and analyze data to improve
patient care, control costs, respond to surveys, or use in research studies.
7. Repairs torn charts, replacing torn pockets and broken fasteners.
8. Other duties as assigned.
Education: High school diploma. Associate’s degree from a community/junior college
preferred.
Experience: Minimum two years of medical records clerk/health information technician
experience, preferably in medical practice setting.
Advancing Leaders. Advancing Practices.TM
104 Inverness Terrace East . Englewood, CO 80112 . T 303.799.1111 . F 303.784.6110 . mgma.org
Other Requirements: Registered health information technician (RHIT) designation
preferred, but not required. Offered by the American Health Information Management
Association; designation awarded after successfully completing written exam.
Performance Requirements:
Knowledge:
1. Knowledge of medical records work procedures.
2. Knowledge of computer applications.
3. Knowledge of medical terminology.
4. Knowledge of legal and ethical considerations related to patient information.
Skills:
1. Skill in putting information in preferred medical record system, meeting clinic
standards.
2. Skill in dealing with masses of information in organized manner.
3. Skill in using computer and medical records software.
4. Skill in using courteous and professional telephone manner.
5. Skill in typing at least 35 wpm.
Abilities:
1. Ability to alphabetize and put information (materials, forms, etc.) into
chronological order.
2. Ability to analyze medical records for completeness and accuracy, paying
attention to detail.
3. Ability to schedule time and assignments effectively.
4. Ability to establish and maintain courteous and professional working relationship
with other staff and patients.
5. Ability to work on several projects simultaneously.
Equipment Operated: Range of medical records equipment and supplies, including
computer hardware/software, manual files, and sorters.
Work Environment: Usually pleasant and comfortable offices. Little contact with
patients.
Mental/Physical Requirements: Combination of standing, sitting, bending, and
reaching. May work at computer monitors for prolonged periods with danger of eye strain
and muscle pain. Stress generated if workload is heavy.
Advancing Leaders. Advancing Practices.TM
104 Inverness Terrace East . Englewood, CO 80112 . T 303.799.1111 . F 303.784.6110 . mgma.org