Medical Records Specialists
29-2072.00

This title represents an occupation for which data collection is currently underway.

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 healthcare system. Classify medical and healthcare concepts, including diagnosis, procedures, medical services, and equipment, into the healthcare industry's numerical coding system. Includes medical coders.

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

Occupation-Specific Information

Tasks

  • Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  • Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
  • Consult classification manuals to locate information about disease processes.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Identify, compile, abstract, and code patient data, using standard classification systems.
  • Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
  • Post medical insurance billings.
  • Process and prepare business or government forms.
  • Process patient admission or discharge documents.
  • Protect the security of medical records to ensure that confidentiality is maintained.
  • Release information to persons or agencies according to regulations.
  • 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.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.
  • Review records for completeness, accuracy, and compliance with regulations.
  • Scan patients' health records into electronic formats.
  • Schedule medical appointments for patients.
  • Transcribe medical reports.

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Technology Skills

  • Accounting software — Billing software; NDCMedisoft; QMSoftware Receivables Management; Siemens Soarian Financials
  • Analytical or scientific software — IBM SPSS Statistics Hot technology ; Minitab Hot technology ; SAS statistical software; StataCorp Stata
  • Business intelligence and data analysis software — IBM Cognos Impromptu Hot technology ; MicroStrategy Hot technology ; Qlik Tech QlikView Hot technology ; Tableau Hot technology
  • Calendar and scheduling software — MD Synergy Medical Appointment Scheduling; Scheduling software; Siemens Soarian Scheduling
  • Categorization or classification software — 3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG grouping software
  • Data base management system software — Teradata Database Hot technology
  • Data base reporting software — Microsoft SQL Server Reporting Services SSRS; SAP Crystal Reports Hot technology ; SoftMed ChartRelease
  • Data base user interface and query software — Encoded archival system EAD; Microsoft Access Hot technology ; Microsoft SQL Server Hot technology ; Structured query language SQL Hot technology ; 4 more
  • Desktop communications software — Eko
  • Development environment software — Microsoft Visual Basic Hot technology ; Microsoft Visual Basic Scripting Edition VBScript Hot technology
  • Document management software — Hyland Software OnBase; IDX Systems Patient Chart Tracking; SoftMed ChartLocater; SoftMed ChartReserve; 2 more
  • Electronic mail software — Email software; Microsoft Exchange Hot technology ; Microsoft Outlook Hot technology
  • Enterprise application integration software — IBM InfoSphere DataStage
  • Enterprise resource planning ERP software Hot technology — Microsoft Dynamics Hot technology ; SAP Business Objects
  • Expert system software — Information Resource Products Clinical Coding Expert
  • Graphics or photo imaging software — Graphics software
  • Information retrieval or search software — Coding database software
  • Internet browser software — Web browser software
  • Medical software — Epic Systems Hot technology ; Healthcare common procedure coding system HCPCS Hot technology ; Henry Schein Dentrix Hot technology ; Medical condition coding software Hot technology ; 36 more
  • Metadata management software — CA Erwin Data Modeler
  • Network security and virtual private network VPN equipment software — Virtual private networking VPN software Hot technology
  • Object or component oriented development software — R Hot technology
  • Office suite software — Corel WordPerfect Office Suite; Microsoft Office Hot technology
  • Operating system software — Microsoft Windows Hot technology
  • Optical character reader OCR or scanning software — Scantron imaging software
  • Presentation software — Microsoft PowerPoint Hot technology
  • Process mapping and design software — Microsoft Visio Hot technology
  • Project management software — Microsoft Project Hot technology
  • Spreadsheet software — IBM Lotus 1-2-3; Microsoft Excel Hot technology
  • Transaction security and virus protection software — Encoder software
  • Voice recognition software — Cyber Records MediChart Express; ScanSoft Naturally Speaking; Speech recognition software; Voice dictation software
  • Word processing software — Microsoft Word Hot technology
Hot technology Hot Technologies are requirements frequently included in employer job postings.

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Occupational Requirements

Detailed Work Activities

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Experience Requirements

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 hydroelectric production managers, desktop publishers, electricians, agricultural technicians, barbers, court reporters and simultaneous captioners, and medical assistants.
SVP Range
1-2 years of preparation (6.0 to < 7.0)

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Training & Credentials

State training
Local training
Certifications
Apprenticeships
Have a career path or location in mind? Visit Apprenticeship.gov external site to find apprenticeship opportunities near you.

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Workforce Characteristics

Wages & Employment Trends

Employment data for Medical Dosimetrists, Medical Records Specialists, and Health Technologists and Technicians, All Other.
Industry data for Medical Dosimetrists, Medical Records Specialists, and Health Technologists and Technicians, All Other.
Median wages (2021)
$22.43 hourly, $46,660 annual
State wages
Local wages
Employment (2020)
335,000 employees
Projected growth (2020-2030)
Average (5% to 10%)
Projected job openings (2020-2030)
27,400
State trends
Top industries (2020)

Source: Bureau of Labor Statistics 2021 wage data external site and 2020-2030 employment projections external site. “Projected growth” represents the estimated change in total employment over the projections period (2020-2030). “Projected job openings” represent openings due to growth and replacement.

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Job Openings on the Web

State job openings
Local job openings

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More Information

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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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