Occupation intelligence

medical records clerk

Key facts

Are you detail-oriented and enjoy working with information? As a medical records clerk, you play a vital role in healthcare by ensuring medical staff have timely access to accurate patient information, contributing directly to quality patient care.

Summary

Medical records clerks are essential members of healthcare teams, responsible for the organization and maintenance of patient records. Your work involves both physical and electronic systems, ensuring information is readily available, secure, and compliant with regulations. You'll often be the point of contact for retrieving records and updating information as needed, supporting doctors, nurses, and other healthcare professionals.

Key responsibilities
  • • Organize and maintain both paper and electronic patient records, ensuring accuracy and completeness.
  • • Transfer patient information from paper records to electronic health record (EHR) systems.
  • • Retrieve medical records promptly and efficiently upon request from medical staff.

Are you detail-oriented and enjoy working with information? As a medical records clerk, you play a vital role in healthcare by ensuring medical staff have timely access to accurate patient information, contributing directly to quality patient care.

Healthcare & Human Services Short-cycle tertiary education
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Day in the life

What people in this role usually do

Healthcare & Human Services

Day in the life

A typical day as a medical records clerk

09
09:00 · Morning
deliver case notes
Deliver the appropriate case notes in a timely manner to those requesting them.
10
10:30 · Mid-morning
archive healthcare users' records
Properly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.
12
12:00 · Midday
collect statistics on medical records
Perform statistical analysis of various medical records of the healthcare facility, referring to the number of hospital admissions, discharges or waiting lists.
14
14:00 · Afternoon
comply with quality standards related to healthcare practice
Apply quality standards related to risk management, safety procedures, patients feedback, screening and medical devices in daily practice, as they are recognized by the national professional associations and authorities.
15
15:30 · Late afternoon
collect healthcare user's general data
Collect qualitative and quantitative data related to the healthcare user's anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests performed by the practitioner.
17
17:00 · Wrap-up
display medical problems
Emphasize significant medical issues in a way that the attention of any healthcare professional using the record is directed on them.

Task order is illustrative. Individual days vary.

Software & Technologies & Knowledge areas
Software & Technologies
3M EncoderAllscripts EHRAmazing ChartsAmerican Medical Association CodeManagerAzalea Health Azalea EHRBilling softwareCoding database softwareComChart EMRComputerized indexing systemsCorel WordPerfect Office SuiteCyber Records MediChart ExpressDigital Imaging Communications in Medicine DICOM medical imaging softwareDRG grouping softwareeClinicalWorks EHR softwareEHS CareRevolutionEkoElectronic medical record EMR softwareElectronic medical record EMR systemsElekta METRIQEmail software
Knowledge areas
  • administrative tasks in a medical environment

    The medical administrative tasks such as registration of patients, appointment systems, record keeping of patients information and repeated precribing.

  • clinical coding

    The matching of clinical statements with standard codes of illnesses and treatments through use of a classification system.

  • data storage

    The physical and technical concepts of how digital data storage is organised in specific schemes both locally, such as hard-drives and random-access memories (RAM) and remotely, via network, internet or cloud.

  • document management

    The methodology of tracking, managing and storing documents in a systematic and organised manner as well as keeping a record of the versions created and modified by specific users (history tracking).

  • health records management

    The procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of records.

  • professional documentation in health care

    The written standards applied in the health care professional environments for documentation purposes of one`s activity.

Cross-sector skills
  • database
  • health care legislation
  • health care system
Essential skills
maintaining or preparing medical documentation
  • deliver case notes

    Deliver the appropriate case notes in a timely manner to those requesting them.

  • manage healthcare users' data

    Keep accurate client records which also satisfy legal and professional standards and ethical obligations in order to facilitate client management, ensuring that all clients' data (including verbal, written and electronic) are treated confidentially.

  • perform clinical coding procedures

    Match and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.

managing information
  • archive healthcare users' records

    Properly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.

  • manage digital archives

    Create and maintain computer archives and databases, incorporating latest developments in electronic information storage technology.

complying with operational procedures
  • follow clinical guidelines

    Follow agreed protocols and guidelines in support of healthcare practice which are provided by healthcare institutions, professional associations, or authorities and also scientific organisations.

  • adhere to organisational guidelines

    Adhere to organisational or department specific standards and guidelines. Understand the motives of the organisation and the common agreements and act accordingly.

gathering information from physical or electronic sources
  • collect healthcare user's general data

    Collect qualitative and quantitative data related to the healthcare user's anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests performed by the practitioner.

  • collect statistics on medical records

    Perform statistical analysis of various medical records of the healthcare facility, referring to the number of hospital admissions, discharges or waiting lists.

entering and transforming information
  • type on electronic devices

    Type fast and flawless on electronic devices such as computers in order to ensure a quick and accurate data entry.

  • process data

    Enter information into a data storage and data retrieval system via processes such as scanning, manual keying or electronic data transfer in order to process large amounts of data.

providing medical advice
  • display medical problems

    Emphasize significant medical issues in a way that the attention of any healthcare professional using the record is directed on them.

protecting privacy and personal data
  • maintain healthcare user data confidentiality

    Comply with and maintain the confidentiality of healthcare users` illness and treatment information.

managing, gathering and storing digital data
  • use electronic health records management system

    Be able to use specific software for the management of health care records, following appropriate codes of practice.

Career progression

Growth Pathways & Similar Roles

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Common questions

Frequently asked questions

What skills are most important for a medical records clerk?
Strong attention to detail, excellent organizational skills, and proficiency in computer systems (especially EHR software) are crucial. Good communication skills are also important for interacting with medical staff and ensuring information is accurate.
Do I need a specific degree to become a medical records clerk?
While a formal degree isn't always required, some employers prefer candidates with an associate's degree in medical assisting, health information technology, or a related field. On-the-job training is common, and experience with data entry and record management is highly valued.
How does the shift to electronic health records affect this role?
The increasing adoption of electronic health records has transformed the role. Medical records clerks now spend more time working with computer systems, scanning documents, and ensuring data accuracy within the EHR. Familiarity with different EHR platforms is a valuable asset.