Skills & competences

Description

Medical records and health information technicians develop, maintain and implement health records processing, storage and retrieval systems in medical facilities and other health care settings to meet the legal, professional, ethical and administrative record-keeping requirements of health services delivery.
Tasks include -
(a) planning, developing, maintaining and operating a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyse information;
(b) transcribing, compiling and processing patient medical records, admission and discharge documents, and other medical reports into record-keeping systems to provide data for patient monitoring and referral, epidemiological monitoring, research, billing, cost control and care improvement;
(c) reviewing records for completeness, accuracy and compliance with regulations;
(d) translating narrative descriptions and numeric information from medical records and other documents on health services delivery into codes associated with standard classification systems;
(e) protecting the security of medical records to ensure that confidentiality is maintained, and releasing information to authorized persons and agencies in accordance with regulations;
(f) supervising clerical and administrative workers involved in the maintenance of medical records.
Examples of the occupations classified here:
- Clinical coder
- Disease registry technician
- Health information clerk
- Medical records analyst
- Medical records clerk
- Medical records technician
- Medical records unit supervisor
Some related occupations classified elsewhere:
- Medical secretary - 3344
- Data entry clerk - 4132
- Filing clerk - 4415
Notes
Occupations included in this unit group normally require knowledge of medical terminology, legal aspects of health information, health data standards and computer- or paper-based data management as obtained through formal education and/or on-the-job training.