MEDICAL RECORDS ASSISTANT L1155

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

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

Examples of Work: Reviews medical records for completeness and accuracy and refers incomplete or inaccurate reports to attending physicians for corrections.

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.

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

Prepares detailed and summarized case reports.

Assembles data on patients and prepares detailed statistical reports.

Transcribes dictated, recorded, or written medical material.

Prepares daily facility census and discharge analysis.

Collects information on reportable diseases and notifies proper authorities.

Records social data on birth and death certificates.

Performs related work as required.

Required Knowledges, Skills, and Abilities: Knowledge of the medical terminology required for proper classification, maintenance, and custody 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 Hospitals and Medicare.

Skill in transcribing oral dictation and in typing accurately from rough draft or plain copy.

Ability to maintain complex medical files and cross-indexes.

Ability to summarize complex medical reports.

Minimum Experience and Training: One year of clerical experience in a medical records department of a hospital or medical school which has included six months of on-the-job training by a registered medical records administrator; and graduation from a standard high school, business school, or medical secretarial school;

or

Any equivalent combination of experience and training.

Date Established or Last Revised

Class Specification - 1976

Evaluation Guide - 1985

Commonwealth Equivalent PSG ST04