Profession medical records clerk

Medical records clerks organise, keep up-to-date and archive patients` records for medical staff availability. They transfer medical information from a patient’s paper records to an electronic template.

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Personality Type

• Conventional / Enterprising

Knowledge

• Database

  The classification of databases, that includes their purpose, characteristics, terminology, models and use such as XML databases, document-oriented databases and full text databases.

• Data storage

  The physical and technical concepts of how digital data storage is organised in specific schemes both locally, such as hard-drives and random-access memories (RAM) and remotely, via network, internet or cloud.

• Administrative tasks in a medical environment

  The medical administrative tasks such as registration of patients, appointment systems, record keeping of patients information and repeated precribing.

• Medical terminology

  The meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.

• Professional documentation in health care

  The written standards applied in the health care professional environments for documentation purposes of one`s activity.

• Health care legislation

  The patients` rights and responsibilities of health practitioners and the possible repercussions and prosecutions in relation to medical treatment negligence or malpractice.

• Health care system

  The structure and function of health care services.

• Document management

  The methodology of tracking, managing and storing documents in a systematic and organised manner as well as keeping a record of the versions created and modified by specific users (history tracking).

• Medical informatics

  The processes and tools used for the analysis and dissemination of medical data through computerized systems.

• Clinical coding

  The matching of clinical statements with standard codes of illnesses and treatments through use of a classification system.

• Health records management

  The procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of records.

Skills

• Adhere to organisational guidelines

  Adhere to organisational or department specific standards and guidelines. Understand the motives of the organisation and the common agreements and act accordingly.

• Type on electronic devices

  Type fast and flawless on electronic devices such as computers in order to ensure a quick and accurate data entry.

• Apply organisational techniques

  Employ a set of organisational techniques and procedures which facilitate the achievement of the goals set. Use these resources efficiently and sustainably, and show flexibility when required.

• Use electronic health records management system

  Use specific software for the management of health care records, following appropriate codes of practice.

• Archive healthcare users' records

  Properly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.

• Perform clinical coding procedures

  Match and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.

• Collect healthcare user's general data

  Collect qualitative and quantitative data related to the healthcare user's anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests performed by the practitioner.

• Display medical problems

  Emphasize significant medical issues in a way that the attention of any healthcare professional using the record is directed on them.

• Perform backups

  Implement backup procedures to backup data and systems to ensure permanent and reliable system operation. Execute data backups in order to secure information by copying and archiving to ensure integrity during system integration and after data loss occurrence.

• Manage digital archives

  Create and maintain computer archives and databases, incorporating latest developments in electronic information storage technology.

• Manage healthcare users' data

  Keep accurate client records which also satisfy legal and professional standards and ethical obligations in order to facilitate client management, ensuring that all clients' data (including verbal, written and electronic) are treated confidentially.

• Follow clinical guidelines

  Follow agreed protocols and guidelines in support of healthcare practice which are provided by healthcare institutions, professional associations, or authorities and also scientific organisations.

• Identify patients' medical records

  Locate, retrieve and present medical records, as requested by authorized medical personnel.

• Work in multidisciplinary health teams

  Participate in the delivery of multidisciplinary health care, and understand the rules and competences of other healthcare related professions.

• Maintain healthcare user data confidentiality

  Comply with and maintain the confidentiality of healthcare users` illness and treatment information.

• Deliver case notes

  Deliver the appropriate case notes in a timely manner to those requesting them.

• Comply with quality standards related to healthcare practice

  Apply quality standards related to risk management, safety procedures, patients feedback, screening and medical devices in daily practice, as they are recognized by the national professional associations and authorities.

• Collect statistics on medical records

  Perform statistical analysis of various medical records of the healthcare facility, referring to the number of hospital admissions, discharges or waiting lists.

• Process data

  Enter information into a data storage and data retrieval system via processes such as scanning, manual keying or electronic data transfer in order to process large amounts of data.

Optional knowledge and skills

Source: Sisyphus ODB