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Summary Report for:
29-2071.00 - Medical Records and Health Information Technicians

Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system.

Sample of reported job titles: Coder, Health Information Clerk, Health Information Specialist, Health Information Technician (Health Information Tech), Medical Records Analyst, Medical Records Clerk, Medical Records Coordinator, Medical Records Director, Medical Records Technician (Medical Records Tech), Registered Health Information Technician (RHIT)

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Tasks  |  Tools & Technology  |  Knowledge  |  Skills  |  Abilities  |  Work Activities  |  Detailed Work Activities  |  Work Context  |  Job Zone  |  Education  |  Credentials  |  Interests  |  Work Styles  |  Work Values  |  Related Occupations  |  Wages & Employment  |  Job Openings  |  Additional Information

Tasks

  • Protect the security of medical records to ensure that confidentiality is maintained. See more occupations related to this task.
  • Review records for completeness, accuracy, and compliance with regulations. See more occupations related to this task.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel. See more occupations related to this task.
  • Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software. See more occupations related to this task.
  • Process patient admission or discharge documents. See more occupations related to this task.
  • Transcribe medical reports. See more occupations related to this task.
  • Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings. See more occupations related to this task.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer. See more occupations related to this task.
  • Identify, compile, abstract, and code patient data, using standard classification systems. See more occupations related to this task.
  • Release information to persons or agencies according to regulations. See more occupations related to this task.
  • Plan, develop, maintain, or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information. See more occupations related to this task.
  • Prepare statistical reports, narrative reports, or graphic presentations of information, such as tumor registry data for use by hospital staff, researchers, or other users. See more occupations related to this task.
  • Post medical insurance billings. See more occupations related to this task.
  • Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts. See more occupations related to this task.
  • Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department. See more occupations related to this task.
  • Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds. See more occupations related to this task.
  • Train medical records staff. See more occupations related to this task.
  • Process and prepare business or government forms. See more occupations related to this task.
  • Consult classification manuals to locate information about disease processes. See more occupations related to this task.
  • Develop in-service educational materials. See more occupations related to this task.

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Tools & Technology

Tools used in this occupation:

  • Bar code reader equipment — Barcode scanners See more occupations related to this tool.
  • Compact disc CD or labeling printers — Label printers See more occupations related to this tool.
  • Desktop calculator — 10-key calculators See more occupations related to this tool.
  • Desktop computers See more occupations related to this tool.
  • Dictation machines — Dictaphones See more occupations related to this tool.
  • Encoder decoder equipment — Encoders See more occupations related to this tool.
  • Laser fax machine — Laser facsimile machines See more occupations related to this tool.
  • Laser printers See more occupations related to this tool.
  • Light stylus — Light pens See more occupations related to this tool.
  • Magnetic stripe readers and encoders — Credit card processing machines See more occupations related to this tool.
  • Medical charting systems components or accessories — Barcode attachment equipment See more occupations related to this tool.
  • Microfiche or microfilm viewer components or accessories — Microfiche viewing machines; Microfilm viewing machines See more occupations related to this tool.
  • Notebook computers See more occupations related to this tool.
  • Optical character recognition systems — Optical readers and writers See more occupations related to this tool.
  • Paper shredding machines or accessories — Paper shredders See more occupations related to this tool.
  • Personal computers See more occupations related to this tool.
  • Postal scales See more occupations related to this tool.
  • Premise branch exchange PBX systems — Switchboards See more occupations related to this tool.
  • Scanners — Flat-top scanners See more occupations related to this tool.
  • Special purpose telephones — Multi-line telephone systems See more occupations related to this tool.
  • Tablet computers See more occupations related to this tool.
  • Touch screen monitors See more occupations related to this tool.
  • Typewriters See more occupations related to this tool.

Technology used in this occupation:

  • Accounting software — Billing software; NDCMedisoft software; QMSoftware Receivables Management; Siemens Soarian Financials See more occupations related to this technology.
  • Calendar and scheduling software — MD Synergy Medical Appointment Scheduling; Scheduling software; Siemens Soarian Scheduling See more occupations related to this technology.
  • Categorization or classification software — 3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG Grouper software * See more occupations related to this technology.
  • Data base reporting software — SoftMed ChartRelease See more occupations related to this technology.
  • Data base user interface and query software — EAD Systems software; Microsoft Access; O-HEAP software; Purkinje Dossier (see all 7 examples) See more occupations related to this technology.
  • Document management software — Fox Meadows Accent Data Manager; Hyland Software OnBase; SoftMed ChartLocater; SoftMed ChartReserve (see all 6 examples) See more occupations related to this technology.
  • Electronic mail software — Email software See more occupations related to this technology.
  • Expert system software — Information Resource Products Clinical Coding Expert See more occupations related to this technology.
  • Graphics or photo imaging software — Graphics software See more occupations related to this technology.
  • Information retrieval or search software — Coding database software See more occupations related to this technology.
  • Internet browser software — Web browser software See more occupations related to this technology.
  • Medical software — eClinicalWorks software; Electronic medical record EMR software; Visionary Medical Systems Visionary OFFICE PM; Welford Chart Notes (see all 37 examples) See more occupations related to this technology.
  • Office suite software — Microsoft Office software See more occupations related to this technology.
  • Optical character reader OCR or scanning software — Scantron imaging software See more occupations related to this technology.
  • Presentation software — Microsoft PowerPoint See more occupations related to this technology.
  • Spreadsheet software — IBM Lotus 1-2-3; Microsoft Excel See more occupations related to this technology.
  • Transaction security and virus protection software — Encoder software See more occupations related to this technology.
  • Voice recognition software — Cyber Records MediChart Express; ScanSoft Naturally Speaking; Speech recognition software; Voice dictation software See more occupations related to this technology.
  • Word processing software — Corel WordPerfect software; Microsoft Word See more occupations related to this technology.

* Software developed by a government agency and/or distributed as freeware or shareware.

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Knowledge

  • Clerical — Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology. See more occupations related to this knowledge.
  • English Language — Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar. See more occupations related to this knowledge.
  • Computers and Electronics — Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming. See more occupations related to this knowledge.
  • Customer and Personal Service — Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction. See more occupations related to this knowledge.

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Skills

  • Reading Comprehension — Understanding written sentences and paragraphs in work related documents. See more occupations related to this skill.
  • Active Listening — Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. See more occupations related to this skill.
  • Critical Thinking — Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. See more occupations related to this skill.
  • Speaking — Talking to others to convey information effectively. See more occupations related to this skill.
  • Writing — Communicating effectively in writing as appropriate for the needs of the audience. See more occupations related to this skill.

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Abilities

  • Near Vision — The ability to see details at close range (within a few feet of the observer). See more occupations related to this ability.
  • Oral Comprehension — The ability to listen to and understand information and ideas presented through spoken words and sentences. See more occupations related to this ability.
  • Written Comprehension — The ability to read and understand information and ideas presented in writing. See more occupations related to this ability.
  • Oral Expression — The ability to communicate information and ideas in speaking so others will understand. See more occupations related to this ability.
  • Category Flexibility — The ability to generate or use different sets of rules for combining or grouping things in different ways. See more occupations related to this ability.
  • Deductive Reasoning — The ability to apply general rules to specific problems to produce answers that make sense. See more occupations related to this ability.
  • Information Ordering — The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations). See more occupations related to this ability.
  • Speech Recognition — The ability to identify and understand the speech of another person. See more occupations related to this ability.
  • Written Expression — The ability to communicate information and ideas in writing so others will understand. See more occupations related to this ability.

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Work Activities

  • Getting Information — Observing, receiving, and otherwise obtaining information from all relevant sources. See more occupations related to this activity.
  • Processing Information — Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data. See more occupations related to this activity.
  • Documenting/Recording Information — Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form. See more occupations related to this activity.
  • Interacting With Computers — Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information. See more occupations related to this activity.
  • Organizing, Planning, and Prioritizing Work — Developing specific goals and plans to prioritize, organize, and accomplish your work. See more occupations related to this activity.
  • Communicating with Supervisors, Peers, or Subordinates — Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person. See more occupations related to this activity.
  • Updating and Using Relevant Knowledge — Keeping up-to-date technically and applying new knowledge to your job. See more occupations related to this activity.
  • Establishing and Maintaining Interpersonal Relationships — Developing constructive and cooperative working relationships with others, and maintaining them over time. See more occupations related to this activity.
  • Evaluating Information to Determine Compliance with Standards — Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards. See more occupations related to this activity.
  • Performing Administrative Activities — Performing day-to-day administrative tasks such as maintaining information files and processing paperwork. See more occupations related to this activity.
  • Analyzing Data or Information — Identifying the underlying principles, reasons, or facts of information by breaking down information or data into separate parts. See more occupations related to this activity.
  • Identifying Objects, Actions, and Events — Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events. See more occupations related to this activity.
  • Communicating with Persons Outside Organization — Communicating with people outside the organization, representing the organization to customers, the public, government, and other external sources. This information can be exchanged in person, in writing, or by telephone or e-mail. See more occupations related to this activity.
  • Monitor Processes, Materials, or Surroundings — Monitoring and reviewing information from materials, events, or the environment, to detect or assess problems. See more occupations related to this activity.
  • Making Decisions and Solving Problems — Analyzing information and evaluating results to choose the best solution and solve problems. See more occupations related to this activity.

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Detailed Work Activities

  • Record patient medical histories. See more occupations related to this activity.
  • Process healthcare paperwork. See more occupations related to this activity.
  • Perform clerical work in medical settings. See more occupations related to this activity.
  • Prepare official health documents or records. See more occupations related to this activity.
  • Maintain medical facility records. See more occupations related to this activity.
  • Enter patient or treatment data into computers. See more occupations related to this activity.
  • Monitor medical facility activities to ensure adherence to standards or regulations. See more occupations related to this activity.
  • Train caregivers or other non-medical personnel. See more occupations related to this activity.
  • Maintain medical or professional knowledge. See more occupations related to this activity.
  • Process medical billing information. See more occupations related to this activity.
  • Supervise medical support personnel. See more occupations related to this activity.
  • Prepare healthcare training materials. See more occupations related to this activity.
  • Present medical research reports. See more occupations related to this activity.
  • Manage healthcare operations. See more occupations related to this activity.

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Work Context

  • Importance of Being Exact or Accurate — 74% responded “Extremely important.” See more occupations related to this work context.
  • Importance of Repeating Same Tasks — 78% responded “Extremely important.” See more occupations related to this work context.
  • Indoors, Environmentally Controlled — 86% responded “Every day.” See more occupations related to this work context.
  • Spend Time Sitting — 66% responded “Continually or almost continually.” See more occupations related to this work context.
  • Face-to-Face Discussions — 60% responded “Every day.” See more occupations related to this work context.
  • Telephone — 65% responded “Every day.” See more occupations related to this work context.
  • Work With Work Group or Team — 43% responded “Extremely important.” See more occupations related to this work context.
  • Contact With Others — 42% responded “Contact with others most of the time.” See more occupations related to this work context.
  • Electronic Mail — 67% responded “Every day.” See more occupations related to this work context.
  • Structured versus Unstructured Work — 53% responded “Some freedom.” See more occupations related to this work context.
  • Freedom to Make Decisions — 44% responded “Some freedom.” See more occupations related to this work context.
  • Time Pressure — 40% responded “Every day.” See more occupations related to this work context.
  • Spend Time Making Repetitive Motions — 39% responded “Continually or almost continually.” See more occupations related to this work context.
  • Frequency of Decision Making — 56% responded “Every day.” See more occupations related to this work context.
  • Impact of Decisions on Co-workers or Company Results — 37% responded “Important results.” See more occupations related to this work context.
  • Sounds, Noise Levels Are Distracting or Uncomfortable — 36% responded “Every day.” See more occupations related to this work context.
  • Coordinate or Lead Others — 42% responded “Important.” See more occupations related to this work context.
  • Deal With External Customers — 25% responded “Extremely important.” See more occupations related to this work context.
  • Letters and Memos — 31% responded “Never.” See more occupations related to this work context.
  • Spend Time Using Your Hands to Handle, Control, or Feel Objects, Tools, or Controls — 38% responded “Continually or almost continually.” See more occupations related to this work context.
  • Physical Proximity — 56% responded “Slightly close (e.g., shared office).” See more occupations related to this work context.

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Job Zone

Title Job Zone Three: Medium Preparation Needed
Education Most occupations in this zone require training in vocational schools, related on-the-job experience, or an associate's degree.
Related Experience Previous work-related skill, knowledge, or experience is required for these occupations. For example, an electrician must have completed three or four years of apprenticeship or several years of vocational training, and often must have passed a licensing exam, in order to perform the job.
Job Training Employees in these occupations usually need one or two years of training involving both on-the-job experience and informal training with experienced workers. A recognized apprenticeship program may be associated with these occupations.
Job Zone Examples These occupations usually involve using communication and organizational skills to coordinate, supervise, manage, or train others to accomplish goals. Examples include food service managers, electricians, agricultural technicians, legal secretaries, occupational therapy assistants, and medical assistants.
SVP Range (6.0 to < 7.0)

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Education


Percentage of Respondents
Education Level Required
48   High school diploma or equivalent Help
21   Some college, no degree
20   Associate's degree

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Credentials

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Interests

Interest code: CE

  • Conventional — Conventional occupations frequently involve following set procedures and routines. These occupations can include working with data and details more than with ideas. Usually there is a clear line of authority to follow. See more occupations related to this interest.
  • Enterprising — Enterprising occupations frequently involve starting up and carrying out projects. These occupations can involve leading people and making many decisions. Sometimes they require risk taking and often deal with business. See more occupations related to this interest.

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Work Styles

  • Attention to Detail — Job requires being careful about detail and thorough in completing work tasks. See more occupations related to this work style.
  • Cooperation — Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude. See more occupations related to this work style.
  • Dependability — Job requires being reliable, responsible, and dependable, and fulfilling obligations. See more occupations related to this work style.
  • Integrity — Job requires being honest and ethical. See more occupations related to this work style.
  • Independence — Job requires developing one's own ways of doing things, guiding oneself with little or no supervision, and depending on oneself to get things done. See more occupations related to this work style.
  • Initiative — Job requires a willingness to take on responsibilities and challenges. See more occupations related to this work style.
  • Adaptability/Flexibility — Job requires being open to change (positive or negative) and to considerable variety in the workplace. See more occupations related to this work style.
  • Self Control — Job requires maintaining composure, keeping emotions in check, controlling anger, and avoiding aggressive behavior, even in very difficult situations. See more occupations related to this work style.
  • Analytical Thinking — Job requires analyzing information and using logic to address work-related issues and problems. See more occupations related to this work style.
  • Achievement/Effort — Job requires establishing and maintaining personally challenging achievement goals and exerting effort toward mastering tasks. See more occupations related to this work style.
  • Concern for Others — Job requires being sensitive to others' needs and feelings and being understanding and helpful on the job. See more occupations related to this work style.
  • Persistence — Job requires persistence in the face of obstacles. See more occupations related to this work style.
  • Stress Tolerance — Job requires accepting criticism and dealing calmly and effectively with high stress situations. See more occupations related to this work style.
  • Social Orientation — Job requires preferring to work with others rather than alone, and being personally connected with others on the job. See more occupations related to this work style.
  • Leadership — Job requires a willingness to lead, take charge, and offer opinions and direction. See more occupations related to this work style.
  • Innovation — Job requires creativity and alternative thinking to develop new ideas for and answers to work-related problems. See more occupations related to this work style.

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Work Values

  • Relationships — Occupations that satisfy this work value allow employees to provide service to others and work with co-workers in a friendly non-competitive environment. Corresponding needs are Co-workers, Moral Values and Social Service. See more occupations related to this work value.
  • Support — Occupations that satisfy this work value offer supportive management that stands behind employees. Corresponding needs are Company Policies, Supervision: Human Relations and Supervision: Technical. See more occupations related to this work value.
  • Independence — Occupations that satisfy this work value allow employees to work on their own and make decisions. Corresponding needs are Creativity, Responsibility and Autonomy. See more occupations related to this work value.

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Related Occupations

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Wages & Employment Trends

Median wages (2014) $17.26 hourly, $35,900 annual
State wages Local Salary Info
 
Employment (2012) 186,000 employees
Projected growth (2012-2022) Much faster than average (22% or higher) Much faster than average (22% or higher)
Projected job openings (2012-2022) 90,400
State trends Employment Trends
 
Top industries (2012)

Source: Bureau of Labor Statistics 2014 wage data external site and 2012-2022 employment projections external site. "Projected growth" represents the estimated change in total employment over the projections period (2012-2022). "Projected job openings" represent openings due to growth and replacement.

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Job Openings on the Web

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Sources of Additional Information

Disclaimer: Sources are listed to provide additional information on related jobs, specialties, and/or industries. Links to non-DOL Internet sites are provided for your convenience and do not constitute an endorsement.

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