Medical Records Technician, GS-0675 Page 2
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OCCUPATIONAL INFORMATION
Health care facilities maintain a permanent medical record that contains health care
information to support the diagnosis and justify treatment rendered on each patient. This record
includes the patient's medical history, physical examination results, X-ray and laboratory reports,
diagnosis and treatment plans, and orders and notes from doctors, nurses, and other health care
professionals. Accurate medical records are essential for clinical, legal, and fiscal purposes, for
correct and prompt diagnosis and treatment of illnesses and injuries, and for continuity of care.
Medical records also serve as a source of information for other uses. They provide background
and documentation for insurance claims, legal actions, professional review of prescribed
treatments and medications, and training of health professionals. Medical records provide useful
information for research and resource management planning purposes. They contain data for
clinical studies, evaluation of costs of various medical procedures, and assessment of health needs,
and justify the management costs associated with treatment.
Medical records clerks and technicians assemble, analyze, code, abstract, report, and maintain
medical records information in manual and automated records systems. They organize and check
medical records for completeness, accuracy, and compliance with regulatory requirements. When
assembling a patient's medical record, they first ensure the medical record is complete. With a
paper medical record, this means that all documentation is present in appropriate format and
sequence, identified, and signed. Employees assure that all documents reach the record before
coding is done. In a growing number of medical centers, the medical staff use computers rather
than the traditional paper record to note patient care information. In these hospitals, technicians
use their own computer terminals to retrieve information from the patient's record in the hospital's
central computer. A few medical centers are developing larger patient care information systems
using optical disks and satellite transmission of data from one facility to another.
Coding
Employees must apply a thorough knowledge of various medical and clinical processes such
as disease, illness, or injury and conditions (e.g., pregnancy, psychological) and their
interrelationships to code the record correctly. They abstract all the necessary information and
assign codes which most accurately describe each documented diagnosis, surgical procedure, and
special therapy or procedure according to established guidelines and practices. Where multiple
diagnoses and procedures are listed, they must relate each surgical procedure to the proper
diagnosis. They select and assign a principal code along with other appropriate codes.
Technicians must assure that the diagnosis responsible for the length of stay is appropriately
identified and that the secondary diagnoses are sequenced properly in order to assure maximum
allocation under the Diagnostic Related Groups (DRG's) System. Because information in the
medical record is the basis for reimbursement as well as clinical decision making, coding entries
must be complete and accurate. A coding error can mean a financial loss for the hospital because
the amount of reimbursement depends on the correct coding of diagnoses and procedures to
ensure the appropriate DRG's assignment.