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 have a variety of data entry and recordkeeping tasks. They may gather patients’ medical histories, symptoms, test results, treatments, and other health information and enter the details into electronic health records (EHR) systems. Some workers categorize medical information for purposes such as insurance reimbursement and providing data to clinicians.

When handling medical records, these workers follow administrative, ethical, and legal requirements for safeguarding patient privacy. Medical records specialists also may serve as gatekeepers for access to patient files. They ensure access only to authorized people and retrieve, scan, and transmit files according to established protocols.

Medical coders assign the diagnosis and procedure codes for patient care, population health statistics, and billing purposes. For example, they might review patient information for preexisting conditions, such as diabetes, to ensure proper coding of patient data. They also work as the liaison between healthcare providers and billing offices.

Although medical records specialists do not provide direct patient care, they work regularly with registered nurses and other healthcare workers. They meet with these workers to clarify diagnoses or to get additional information.

A High school and experience in a healthcare setting are enough to qualify for some positions, but others may require a postsecondary certificate or an associate’s or bachelor’s degree.

High school students may benefit from taking classes in subjects such as biology, computer science, and anatomy.

Community colleges and technical schools offer certificate and associate’s degree programs for medical records specialists. These programs typically include courses in medical terminology, health data requirements and standards, and classification and coding systems.

Medical records specialists may advance to become health information technologists or medical registrars or medical or health services managers after completing a higher certification program or earning a degree in health information technology. Requirements vary by facility.