Medical Records Assistant Job Description Example

By | August 3, 2015
Medical Records Assistant job description, duties, tasks, and responsibilities

Medical Records Assistants documents patients’ health information for record purpose.

Medical Records Assistant Job Description Example

What Does a Medical Records Assistant Do?

A medical records assistant is someone who documents patients’ health and personal information in stipulated files for record keeping.

His/her job description entails having all aspects of patients’ treatment in the clinic put down for future reference.

Upon a patient’s arrival and meeting with the physician, the assistant will take the record of the patient’s symptoms and their general health condition as instructed by the physician to identify their state of health at that moment.

The documentation of a patient’s health condition is also important to avoid misinformation and false claims by patients, which could jeopardize the physician’s competence, as well as the reputation of the clinic in general.

After a patient’s specimens must have been tested in the laboratory, the assistant will ensure a copy of the result is kept in the patient’s file.

His/her role also includes entering the result data into the computer system where applicable. This is important in case of further treatment of the patient, as it gives evidence of their health history, which is required for effective treatment and overall health management of the patient.

When a patient’s health condition is determined, the physician will specify the treatment plan to be administered to them.

The medical records assistant takes it up from there by making detailed notes of treatment procedures that have been prescribed to serve as evidence of treatment techniques employed on the patient. This may generally help to identify more effective treatment procedures.

Medical Records Assistant Job Description Example

Individuals who work as assistants in medical record units of most healthcare facilities usually carry out the tasks, duties, and responsibilities highlighted in the job description example below:

  • Ensure that all documents are completely and accurately filled and are verified for authenticity
  • Collect patients’ demographic data for easy identification and contact in cases of emergency and correspondence. This is important to prevent criminal acts such as impersonation, or fraud by some unauthorized individuals; and to provide relevant authorities with accurate information in the course of their duties
  • Work with insurance companies to fill in patients’ insurance information when verifying and facilitating their insurance claims
  • Arrange patients’ files in orderly manner for easy access and to avoid confusion when sorting them out
  • Keep patients’ files safe
  • Work with physicians and other clinic team members in getting complete information of patients’ health; request for other information that are not available in patients’ records
  • Enter information in patients’ files into the clinic’s electronic database as backup for retrieval
  • May develop clinic codes for patients’ information usage to protect patients’ privacy. This includes handling of patients’ health information with a high level of confidentiality
  • Carry out periodic review of patients’ medical records to ensure that old and outdated information is updated to meet current status
  • Create numbers and assign them to each patient for easy identification of their records
  • Make patients’ charts and records available to relevant department in accordance with clinic procedures
  • Compile both new and old medical records of clients for clarification and comprehension
  • Maintain communication with patients so as to be aware of changes in their health condition quick enough
  • Work with the various departments of the clinic to have a smooth flow of information regarding patients’ treatments and visits to the clinic for record keeping
  • Prepare clients’ billing information for payment after treatment
  • Keep records of clinical supplies and orders that have been made

Medical Records Assistant Resume Preparation

The job description sample given above contains information about the work activities of the medical records assistant position, which can be used in preparing certain sections of the resume for the position, including the job experience section.

Requirements – Skills, Knowledge, and Abilities – for the Medical Records Assistant Position

The skills and qualifications that are majorly required by employers and hiring managers from applicants seeking to work as assistants in a medical records office include the following:

  • Computer skills: Medical assistants at the records unit of a clinic must be able to use different computer software packages like Excel and Word to document information
  • Organizational skills: The assistant must possess a high level of organizational skills to be able to keep and sort files orderly
  • Retentive memory: To be able to record information accurately, assistants working at the medical records must be able to remember events that happen in the clinic vividly
  • Time management: This is an important skill for the assistant to have to be able to record patients’ information promptly so that their documents are ready as at when due for issuance to authorized officials and other departments in the clinic