Medical records job description

This post includes 3 parts: duties list, job qualification and job description writing tips for Medical records in details. A complete job description concludes Medical records key duties/responsibilities, Medical records job qualifications (knowledge, education, skills, abilities, experience…KSA model) and other ones such as daily tasks, key activities, key/core competencies, job functions/purpose…

I. List of Medical records duties:

1.    Assembles and analyzes medical records in accordance with established policy. Maintains accuracy and integrity of all medical records systems, including medical record number assignment, electronic document management, filing, tracking of record locations and all other systems integrated into the medical record department.

2.    Responsible for processing all requests for health information received via mail, telephone, fax or electronically.

3.    Pulls records for routine daily patient visits and record reviews when required for records not stored in electronic format.

4.    Scans various medical reports into the appropriate patient files within the specified time frame.
Responsible for complying with established policy and current consent law for the proper release of all medical records.

5.    Assures all releases of information are handled with security and confidentiality in accordance with proper authorization from patient or legal representative.

6.    Maintains confidentiality of patient's health records and other information as required by applicable laws.

7.    Responsible for compliance with all established medical record policies and procedures and for keeping current on revisions.

II. List of Medical records qualifications

1.     High school diploma or equivalent    

2.     Experience in Medical Records and scanning (preferred)

3.     Experience utilizing Windows-based PC programs (required)

4.     Experience with medical legal record review regarding Californiaworkers compensation codes

5.     Experience in editing reports from a Qualified Medical Evaluation (QME, PQME, AME)

6.     Minimum of 2 years college education, four years preferred

7.     Quick and accurate scanning abilities 

8.     Familiarity with contents of a physician’s office medical chart

9.     Strict attention to detail

10.  Ability to take direction

III. Tips to write job description

1. Too-long job description:

Looking at a too-long job description can frighten the candidates off and drive the away. A job description, no matter how important the job is, should not be included in more than 3 pages. If one focuses on too many things at a time, he shall definitely lose focus on the main items and get overwhelmed by the remaining; So, keep it concisely.

2. Too-short job description:

While too-long can be a problem, too-short is more a problem. It will ruin the meaning of the job description. A too-short one means it lacks necessary details and therefore, the candidate will not be able to understand while reading it.

3. Listing unnecessary functions or job duties:

Just classifying these into the “others” category will save you a lot of effort and space. On the other hand, the job description will become more dilute and easy to be neglected.

4. Key functions

Not listing key functions as required for the job can be a fatal mistake to a job description.

5. Grammar and spelling

Poor grammar and having spelling errors can ruin the job description, too. Never think that as you are the employer, you may have the right to make grammar or spelling errors while requires other not to. A job description with such errors is easily to be mistaken as a fake or ghost ads; as a result, the candidate will turn away from it.

6. Not specific enough:

Be specific and concise; if you don’t address the specific, then what the job description is for. It is for the candidate to understand just exactly what he needs to do or needs to have. Lacking details can confuse the candidates very well.

7. Not having the job description reviewed by others:

This is also a common mistake. One may be subject to bias, but more than one, especially with the help of those external advisor, the job description can be more perfect.

8. Using buzzwords or abbreviations:

In fact, it is not necessary at all to use such in a job description.

9. Using slang or legal words:

Just use common wording to communicate with others and don’t do anything extraordinarily.

10. Not updating the job description:

The same job may require different duties and responsibilities in different times, so, you cannot use the same job description for 2 different times.