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  • Health Information Services

  • The purpose of the Health Information Services (HIS) Department is to support patient care though the establishment, maintenance, control and dissemination of complete and accurate medical records and related patient information.

    Job responsibilities:

    • Provide a communications tool for continuity of care through the department.
    • Support education and research by providing clinical and statistical information
    • Provide information for auditing the quality of care through the medical record
    • Provide legal protection for the patient, physician and hospital

    The importance of medical records

    Medical records are an important tool in the practice of medicine. Medical records:

    • Serve as a basis for planning patient care.
    • Provide a means of communication between physician and other professional groups contributing to patient care.
    • Furnish documentary evidence of the course of the patient's illness and treatment.
    • Serve as a basis for review, study and evaluation of medical care rendered to the patient.

    Positions in the HIS department:

    Clerk

    • Locating, collating, filing, forwarding and photocopying records and materials.
    • Prepares routine reports and/or summaries involving tabulation of numerical data.
    • Operates standard office equipment.
    • Performs a variety of moderately complex clerical functions that require the use of judgment and knowledge of the department's systems and operations.

    Record analysis and incomplete chart analysis clerk

    • Analyzes records of patients discharged in order to ensure that all records are complete prior to being filed.  
    • Notifies physicians of deficiencies and utilizes established procedures to ensure deficiencies are corrected.
    • Performs related clerical and medical records duties as necessary.

    Medical record lead clerk

    • Serves as a lead or resource person for clerical employees.
    • Uses experienced-based knowledge of specific unit/department operations in order to assign work.
    • Establishes work schedules and reviews the work of subordinate clerical employees.
    • Resolves complex and/or sensitive work-related matters. 
    • Regularly performs a variety of clerical duties in addition to lead responsibilities, such as gathering data, preparing reports, taking messages and word processing.

    Education and skill requirements:

    Clerk A

    • High school graduate
    • Three months of job-related experience

    Record Analysis and Incomplete Chart Analysis Clerk

    • High school graduate
    • Interpersonal abilities necessary to tactfully but effectively interact with medical staff and other hospital personnel.
    • Clerical ability to review charts, compile data and maintain records.
    • Three to six months on-the-job training and experience.

    Medical record lead clerk

    • High school graduate
    • Six to 12 months of progressively responsible work experience in order to be familiar with all unit/departmental functions.
    • The ability to operate automated office equipment, including word processing and spreadsheet applications.
    • Administrative ability to function as lead or resource person for clerical employees and coordinate their activities.