Summary Compiles and maintains medical records of patients of health

care delivery system to document patient condition and treatment by

performing the following duties.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Analyzes and reviews medical records for completeness and accuracy of documentation according to specified standards.

Abstracts and codes clinical data such as diseases, operations,

procedures, and therapies on medical records according to specified

standards.

Assigns patient severity of illness index ratings, supplemental codes, and other data as necessary.

Monitors completion of medical records in accordance with time standards.

Audits incomplete records and prepares reports on delinquencies.

Confers with doctors, nurses, and other health personnel to assure complete, current, and accurate medical records.

Compiles, maintains, and reviews logs, reports, and statistical records,

and researches records to locate health data as requested.

Maintains and utilizes a variety of health record indexes and storage and retrieval systems.

Operates computer to process, store, and retrieve health information.

Assists in identification of medical records needed for research using both manual and computer indexes.

Assists Medical Record Director in special studies or research, as needed.

Trains clerical staff in medical record processing activities.

Prepares input for computerized medical information systems and for

processing vital statistics, insurance, and other forms and documents.