JOB DESCRIPTION

Code patient diagnoses and treatments according to medical classification systems and enter the codes into the patient’s records. Use codes in medical software programs to review and analyze patient records and to cross-index medical information.

SKILLS AND APTITUDES NEEDED

Basic knowledge of medical terminology, health, anatomy, physiology, biology, and chemistry Competent with computers Knowledge of legal aspects of health information, coding and abstraction of data, statistics, database management, and quality improvement methods Ability to pay close attention to detail Strong clinical background to analyze the contents of medical records

Medical records technicians assemble patients’ health information and ensure all forms are completed. They assign a code to each diagnosis and procedure. They use a software program to assign the patient to one of several hundred “diagnosis-related groups” (DRG). The DRG determines the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the DRG system.

Technicians use computer programs to tabulate and analyze data to help improve patient care, or control costs for use in legal actions or in response to surveys. This is one of the few health occupations in which there is little or no physical contact with patients. Technicians who work at computer monitors for prolonged periods must guard against eyestrain and muscle pain.