Assessment Template For Medical Records Specialists

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.
Medical Records Specialists


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Popular Job Roles
CoderHealth Information ClerkHealth Information SpecialistHealth Information Technician (Health Information Tech)Medical Records ClerkMedical Records CoordinatorMedical Records Technician (Medical Records Tech)Registered Health Information Technician (RHIT)


Technology Skills
Medical software
Time Limit20 min


  • 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.

Technology Skills

Medical software

Epic Systems, Healthcare common procedure coding system HCPCS, Henry Schein Dentrix, Medical condition coding software

Desktop communications software


Data base user interface and query software

Encoded archival system EAD, Microsoft Access, Microsoft SQL Server, Structured query language SQL

Document management software

Hyland Software OnBase, IDX Systems Patient Chart Tracking, SoftMed ChartLocater, SoftMed ChartReserve

Categorization or classification software

3M Encoder, American Medical Association CodeManager, Computerized indexing systems, DRG grouping software

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