What do medical records specialists do?
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.
This describes a U.S. occupation, not a live vacancy. Individual employers may use different titles and requirements.
Job titles to recognize in your search
O*NET reports these titles for this occupation. Compare the responsibilities in each posting before treating titles as equivalent.
- Coder
- Health Information Clerk
- Health Information Specialist
- Health Information Technician (Health Information Tech)
- Health Records Specialist
- HIM Clerk (Health Information Management Clerk)
- Medical Coder
- Medical Records Clerk
Core tasks to compare with a job posting
- Protect the security of medical records to ensure that confidentiality is maintained.
- Review records for completeness, accuracy, and compliance with regulations.
- Scan patients' health records into electronic formats.
- Release information to persons or agencies according to regulations.
- Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
- Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
- Process patient admission or discharge documents.
- Retrieve patient medical records for physicians, technicians, or other medical personnel.
Prepare an application for this occupation
- Check the employer’s requirements, location, schedule and any licenses against your situation.
- Choose two or three tasks above that match the posting and your actual experience.
- Build a resume evidence worksheet using the skills and software relevant to that employer.
- Practice explaining your contribution, decisions and results before an interview.
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