 Lifespan
Youth
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.
Overall job responsibilities
The importance of medical records
Job positions in the department
Education and skill requirements
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
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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.
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Positions in the HIS department:
-
Locating, collating, filing, forwarding and photocopying
records and materials.
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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 cerk
- 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.
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Education and skill requirements
Clerk A
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.
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