05/27/2011 39030

MEDICAL RECORDS TECHNICIAN

DEFINITION:

This is technical work in the operation of a medical records department at a state correctional facility within the Department of Corrections.

An employee in this job plans, organizes, and performs the technical work of a medical records department where all inmate medical histories are established, classified, and maintained. Work involves maintaining and updating inmate health records; reviewing the records for completeness and accuracy to ensure their applicability for patient treatment, research, and case study; regulating the release of inmate medical information; and ensuring that all materials shared between correctional facilities and outside entities are relevant and appropriate according to applicable laws and regulations. Work is performed under the direction of a Corrections Health Care Administrator or other administrative supervisor and is reviewed for compliance with departmental and facility policies and procedures through reports, conferences, and inspections.

EXAMPLES OF WORK:

Ensures each inmate has a separate and complete medical record.

Creates new medical records for inmates entering the system, reactivates older medical records for inmates returning as new receptions or parole violators, and merges temporary medical records with the inmate’s permanent file.

Reviews medical records for completeness and accuracy, referring inadequate or incomplete records to treatment staff for correction.

Codes or verifies the coding of diseases, operations, special therapies and program services, and treatments.

Regulates the release of information to appropriate departmental personnel and external requestors, to include healthcare providers, insurance companies, attorneys, and others.

Reviews medical records with inmates upon request.

Interviews inmates to identify past medical record history and ensures the completion of authorization forms to request information from previous healthcare providers.

Reviews, prepares, and monitors the transfer of medical records into and out of the facility by completing a transfer checklist, ensuring the medical record is complete, and locating missing information.

Indexes and cross-indexes information contained in medical records.

Compiles pertinent medical information from records and creates abstracts to forward to authorized personnel.

Prepares or provides relevant medical information to be used in the compilation of statistical reports.

Presents or assists in the presentation of medical records information in court cases.

Ensures the facility’s medical records department is operated in accordance with applicable departmental and facility policies and procedures.

Maintains knowledge of current laws and regulations governing the release or sharing of medical information.

Provides information and advice to agency staff regarding medical records administration.

Oversees the facility’s medical records archiving process to include the preparation and transfer of medical records to the State Records Center.

Participates in the filing, withdrawal, and issuance of medical charts and reports.

Provides direction to medical records students participating in an approved education or internship program.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES:

Knowledge of medical recordkeeping principles and practices.

Knowledge of medical terminology required for the proper classification and maintenance of medical records.

Knowledge of the medicolegal aspects relating to the maintenance and release of information from medical records.

Knowledge of statistical principles and techniques as applied to medical records work.

Knowledge of the methods and techniques used to establish and maintain medical filing and recordkeeping systems.

Knowledge of the methods and techniques used in the coding and indexing of medical records.

Ability to establish and maintain effective working relationships.

Ability to communicate effectively in writing.

Ability to communicate effectively orally.

NECESSARY SPECIAL REQUIREMENT:

Possession of a valid Registered Health Information Technician (RHIT) certificate or a Registered Health Information Administrator (RHIA) certificate issued by the American Health Information Management Association (AHIMA), or eligibility for certification including completion of an AHIMA approved RHIT or RHIA Health Information Management education program.

POST EMPLOYMENT REQUIREMENT:

Employees who meet the Necessary Special Requirement based on the eligibility option for the RHIT or RHIA certification must obtain one of these certifications within 12 months of employment.