Keeping and maintaining of all health records for clients.
1. Protect the security of medical records to ensure that confidentiality is maintained.
2. Process patient admission and discharge documents.
3. Review records for completeness, accuracy and compliance with regulations.
4. Compile and maintain patient’s medical records to document condition and treatment and
to provide data for research or cost control and care improvement efforts.
5. Enter data, such as demographic characteristics, history and extent of disease, diagnostic
procedures and treatment into computer.
6. Release information to persons and agencies according to regulations.
7. Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
8. Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department.
9. Transcribe medical reports.
10. Prepare statistical reports, narrative report and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, and other users.
11. Consult classification manuals to locate information about disease processes.
12. Compile medical care and census data for statistical reports on diseases treated, surgery performed, and use of hospital beds.
13. Develop in-service educational materials/ medical library.