Job Code Pay Scale Group Pay Scale Type Bargaining Unit Civil Service or Non-Civil Service Last Executive Board Change Executive Board Change History
39000 04 ST A1 C 585-20 10/12/1994
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10/12/1994 39000


DEFINITION: This is specialized clerical work in the preparation, classification, and abstracting of medical reports.

Employees in this class assist in the initiation and maintenance of medical records by preparing and typing medical reports, abstracts, and summaries, and reviewing and processing medical records to insure their accuracy and completeness. Work includes the coding of physicians' diagnoses using standardized codes such as in the International Classification of Diseases classification system. Work requires a high degree of accuracy and proficiency within the framework of standard methods and procedures. Work is performed under the supervision of a Medical Records Technician, Medical Records Director, Cancer Registry Specialist, or a Cancer Registry Administrator.

EXAMPLES OF WORK: Reviews medical records for completeness and accuracy and refers incomplete or inaccurate reports to attending physicians for correction.

Codes, indexes, and cross-indexes diseases, operations, and special therapies, according to standard nomenclature and classification systems.

Files, withdraws, and issues charts and reports to authorized personnel.

Applies facility policies, regulations and procedures and state and federal accreditation/certification standards for the maintenance of medical records.

Composes and types routine requests for medical information from other facilities, hospitals or agencies.

Prepares detailed and summarized case reports.

Assembles data on patients admitted to the facility and prepares detailed statistical reports.

Transcribes dictated, recorded or written medical material.

Prepares daily facility census and discharge analysis.

Collects information on reportable disease and notifies proper authorities.

Copies medical records in response to correspondence requests from physicians, representatives of insurance companies, and others who have a legitimate interest or need for patient information, with a signed release for records from the patient.

Reviews the maintenance of records through auditing process to ensure presence and timeliness of all required documents.

Records medical information on birth and death certificates.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of the medical terminology and coding required for proper classification and maintenance of medical records.

Knowledge of medical record-keeping methods and techniques as required by various accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations, Health Care Financing Administration, Accreditation Council on services for people with Developmental Disabilities, and the Federal and State Government Medicare and Medical Assistance programs.

Ability to transcribe from cassette recordings clinical staff or clinicians' reports on individual patients.

Ability to type accurately at the rate of 40 words per minute from rough draft or plain copy.

Ability to maintain medical files and cross-indexes.

Ability to summarize medical reports.

MINIMUM EXPERIENCE AND TRAINING: One year of clerical experience in a medical records department of a hospital, or ambulatory acute medical care setting or a licensed nursing facility, which has included six months of experience under the general direction or oversight by a registered Medical Records Technician or Administrator; and graduation from high school;


Graduation from a medical secretarial or medical records program;


Any equivalent combination of experience and training.