Location:

Basic Purpose:  

Positions in this job family are assigned responsibilities related to preparing, classifying and abstracting medical reports in the medical records unit. 

Typical Functions:  

• Reviews medical records for completeness and accuracy and refers incomplete or inaccurate reports to appropriate staff for correction. 

• Prepares statistical, case and other types of reports. 

• Prepares materials and forms and gathers all pertinent information and data for admissions and discharges. 

• Ensures all data is properly coded. 

• Abstracts charts and other patient data in order to respond to requests for information on patients; may make determinations on what materials can legally be released. 

• Assists in the development of medical records policies and procedures. 

• Reviews existing policies and procedures to ensure they are in compliance with federal and state laws and agency rules, regulations and policies. 

• Insures the security and confidentiality of patient medical records. 

• May supply requested information to courts and other judicial inquires. 

Level Descriptor:  

This is the career level where incumbents prepare, classify and abstract medical records, performing assigned duties at the full performance level. 

Knowledge, Skills, Abilities, and Competencies:  

Knowledge, Skills and Abilities required at this level include knowledge of methods and techniques of medical records maintenance; of applicable federal and state laws and agency and facility policies and procedures; of current classification systems; of report writing techniques; and of medical terminology. 

Ability is required to maintain medical records; to code data to records; to review medical records for completeness and accuracy; to prepare reports; to abstract information from records and other patient data; to present information effectively; to establish and maintain effective working relationships with others; and to utilize personal computers. 

Education and Experience:  

Education and Experience requirements at this level consist of eligibility for accreditation with the American Health Information Management Association as a Registered Health Information Technician (RHIT); or two years of experience working with patient records in a medical setting such as a hospital, state institution, medical clinic or a physician’s office. 

Special Requirements:  

Based upon the duties and responsibilities assigned to the position being filled, a user agency may require accreditation with the American Health Information Management Association as a Registered Health Technician (RHIT); or eligibility for registration as a Registered Health Information Administrator (RHIA). 

Some agencies may have determined positions in this job family to be safety sensitive as defined by63 O.S. § 427.8.