Medical Records Specialists

Healthcare Support

Level 4365 of 1200 points

Job description

Medical Records Specialists

Job purpose

To compile, code and maintain the medical records of hospital and clinic patients in accordance with medical, ethical, legal and regulatory requirements, classifying diagnoses, procedures and services into the healthcare coding system, so that records are complete, accurate, secure and usable for billing and research.

Skills

Knowledge of medical terminology and disease processes sufficient to abstract a clinical record, of the classification systems and diagnosis-related groups used to code diagnoses, procedures and services, and of the manuals consulted where a disease process is unfamiliar. Understands the security and disclosure rules governing patient information and the requirements of medical insurance billing, and uses coding software and record retrieval systems. Vocational training, related experience or a two-year qualification is the usual preparation, with one to two years of on-the-job and informal training alongside experienced colleagues; the qualifications incumbents actually hold have not been surveyed.
Consults doctors and other clinical staff to clarify codes or diagnoses where the record is conflicting or unclear, and takes part in the coding team's meetings. Handles requests from physicians and other medical personnel for retrieval of records, responds to agencies seeking release of information, and books medical appointments for patients.
Interprets clinical documentation to select the correct code and assign the patient to the appropriate diagnosis-related group, reviews records for completeness and regulatory compliance, and pursues the detail needed to resolve a case. Precedent is set by the classification systems and manuals, but selection within them calls for judgement.
Works through a flow of admission and discharge documents, coding, scanning, billing postings and information requests, keeping records current as patients move through the service.
Desk-based work using coding and record systems, with keyboard use, handling and scanning of paper records into electronic form, and transcription of medical reports.

Responsibilities

No line management. Works as a member of the coding team and provides a records and coding service to clinicians and to authorised external agencies.
Posts medical insurance billings and prepares business and government forms; the codes assigned determine what is billed and reimbursed. No budget is held and no spending committed.
Ordinary care of a workstation, coding software and the health record indexes and retrieval systems in use, including paper files. No responsibility for stock or plant.
Owns the integrity of the patient medical record: compiles and maintains records documenting condition and treatment, abstracts and codes patient data, enters demographic, diagnostic and treatment information, and maintains the indexes by which records are stored and analysed. Protects the security of records so that confidentiality is maintained, and releases information only as regulations permit. The structure of the data is fixed by the classification systems and regulation.

Effort required

Close, sustained attention to detail in reading clinical documentation and selecting codes, tested against manuals and regulation, with judgement required where the record is incomplete or contradictory.
Handles sensitive personal medical information and holds the line on its disclosure, and raises queries with doctors to have records clarified. No exposure to distress, hostility or conflict is evidenced.
Sedentary record and screen work is implied by the tasks, but posture, movement and exertion have not been surveyed, so no physical demand is evidenced.

Working conditions

The tasks place the work in hospital and clinic record and coding offices. Working conditions have not been surveyed for this occupation, so no hazard, exposure, noise or infection risk is evidenced and none should be assumed.
Hours, shift patterns, on-call expectations, time pressure and autonomy have not been surveyed. What the tasks establish is that the work is governed by the classification systems, disclosure regulations and coding team practice rather than individual discretion.

Skills

40% · 199 points▾

KnowledgeLevel 3 of 8
54 of 144 points
Knowledge of facts, principles and general ideas in a job area. The job requires a range of thinking and practical knowledge to do tasks and solve problems by choosing and using basic methods, tools, materials and information.
Interpersonal and communication skillsLevel 3 of 5
58 of 96 points
Effective communication and interpersonal relationships. The job holder is required to adapt communication to different audiences and foster trust, cooperation and positive working relationships.
Problem-solving skillsLevel 3 of 5
58 of 96 points
Variable problems. The job involves dealing with different kinds of problems that require careful thinking, research into different options or adjusting existing ways of doing things. Guidance and resources may be limited.
Planning and organisational skillsLevel 2 of 5
29 of 72 points
Basic organisational skills required. The job involves planning and organising one's own work within set deadlines. Some input into scheduling and prioritisation of tasks.
Physical skillsLevel 0 of 5
0 of 72 points
Not applicable. The job does not require any particular physical skills (although there is likely to be some physical activity).

Responsibility

35% · 77 points▾

PeopleLevel 0 of 5
0 of 144 points
Does not apply. The job does not require any responsibility for people.
Goods and equipmentLevel 0 of 5
0 of 84 points
Not applicable. The job does not involve any responsibility for goods or equipment.
InformationLevel 3 of 5
58 of 96 points
Moderate responsibility for information. The job involves managing information to ensure it is accurate, of high quality and secure. The job holder may make decisions about the handling of sensitive data.
Financial resourcesLevel 1 of 5
19 of 96 points
Very limited responsibility for financial resources. The job involves handling small amounts of cash or processing simple transactions, such as recording expenses or maintaining basic financial records.

Effort

15% · 65 points▾

Mental effortLevel 3 of 5
36 of 60 points
High level of mental effort. The job involves frequent concentration on complex tasks that require considerable mental effort, such as interpreting complex data.
Psychosocial and emotional effortLevel 2 of 5
29 of 72 points
Occasional psychosocial and emotional effort. The job requires occasional involvement in emotionally demanding situations, such as handling minor conflicts or dealing with upset individuals.
Physical effortLevel 0 of 5
0 of 48 points
Not applicable. The job does not require any physical effort.

Working Conditions

10% · 24 points▾

Environment (physical, psychological or emotional)Level 1 of 5
17 of 84 points
Minimal exposure to hazards or stress. The job involves little or no exposure to physical hazards (e.g. chemicals, moving equipment, noise) and minimal emotional or psychological risks (e.g. occasional routine tasks with no emotional burden). There is minor exposure to dust, dirt, fumes, noise, waste, poor lighting, etc.
Organisational environmentLevel 1 of 5
7 of 36 points
Minimal organisational demands. The job requires standard working hours with no night shifts or irregular schedules. There is little or no need for travel or digital connectivity beyond typical working hours.