How to Become a Medical Records Clerk

A Medical Records Clerk handles all paperwork regarding patient information making sure to follow legal standards implemented by state or federal law.

Medical Records Clerks can find employment in several types of health facilities such as hospitals, nursing homes or private clinics.

They are responsible for making sure all paperwork is handled correctly in order to keep things running smoothly.

Those who want to become a Medical Records Clerk need to have several skills in order to maintain all patient information at a health facility.

Candidates should have superior organizational skills, customer service experience and be able to maintain confidential information regarding patients.

One important aspect of this job is the ability to safeguard patient information according to the Health Insurance Portability and Accountability Act (HIPAA).

By law, a patient’s sensitive information regarding diagnosis, medical past, social security number and contact information is protected by HIPAA.

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This type of information may only be used for medical purposes and a health entity not using patient information according to this act will be held liable for improper use.

Individuals interested in working in the medical field may be interested in the following careers:

  • Medical Lab Technician
  • Health Technician
  • Clinical Laboratory Technician
  • MRI Technician
  • Dental Technician
  • Dialysis Technician

All these jobs entail working with patients or patient information.

Education Requirements to Become a Medical Records Clerk

Individuals who want to become a Medical Records Clerk should have a combination of customer service skills, educational background and certification in order to secure a position in this field.

The minimum educational requirement in order to become a Medical Records Clerk is an Associate’s Degree in Medical Coding.

Some medical facilities train individuals with high school diplomas, but that is not always the case.

Candidates should have thorough knowledge on medical terminology and can fulfill this requirement by attending a program accredited by the Commission on Accreditation for Health Informatics and Information (CAHIIM).

Visit their website at CAHIIM for a list of accredited programs at the Associate’s, Bachelor’s and Master’s levels.

After completing a program, individuals still interested in the medical field as a Medical Records Clerk should take and pass a certification exam in order to be a highly qualified candidate.

The American Health Information Management Association provides certification as Registered Health Information Technician or Registered Health Information Administrator which are both useful in finding a job as a Medical Records Clerk.

Medical Records Clerk Job Description

A Medical Records Clerk is responsible for documenting, maintaining, evaluating and entering patient information into a computer system.

Patient data that is used includes personal information, vital statistics, patient health and any treatments they have undergone.

A patient who has set up an appointment to see a doctor will have that information recorded and kept private for possible use in the future or to be entered into a computer database.

Records can be used for insurance purposes or to compare a patient’s current health status to a previous one.

Assembling patient records is another aspect of the job and a Medical Records Clerk will assure that all information regarding a patient is complete.

A Medical Records Clerk may have patients fill out important paperwork that needs to be kept on file as well as assuring that their medical history and chart is complete and ready to be entered into the computer.

The type of medical information that a Medical Records Clerk may handle and document includes:

  • Medical history
  • Laboratory results
  • Symptoms a patient has
  • Examination results for blood or urine
  • X-Ray results
  • MRI results
  • Diagnoses

Medical Records Clerks may have to discuss patient information with other medical staff to determine whether additional information is needed or to explain a particular diagnosis or symptom.

Medical Records Clerks need to make sure all patient information is current and recorded correctly.

Medical Records Clerk Salary and Career Path

The job outlook for the medical industry as a whole is expected to be outstanding for all positions including for Medical Records Clerks.

The national median wage for related positions such as health information technicians is approximately $30,600 per year.

The salary range for these professionals is approximately $20,000 to $50,000 annually.

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