Health Information Technician I

Basic Purpose :

Positions in this job family are assigned respon sibilities related to preparing, classifying and abstracting medical reports in the medical re co rds unit.

Typical Functions :

• Reviews medical re co rds for co mpleteness and accuracy and refers in co mplete or inaccurate reports to ap pro priate staff for co rr e c tio n .

• Prepares statistical, case and other types of reports.

• Prepares materials and forms and gathers all pertinent information and data for a dmissio ns and discharges.

• Ensures all data is pro perly co ded.

• Abstracts charts and other patient data in order to respond to requests for information on patients; ma y make determinations on what materials can legally be released.

• Assists in the develop ment of me dical re co rds policies and pro cedures.

• Reviews e x isting policies and pro cedures to ensure they are in co mpliance with federal and state laws and agency rules, regulations and pol icies.

• Insures the security and co nfidentiality of patient medical re co rds.

• May supply requested information to co urts and other judicial inquires.

Level Descriptor :

This is the career level where incumbents prepare, classify and abstract medical re co rds, performing assigned duties at the full performance level.

Knowledge, Skills, Abilities, and Co mpetencies :

Knowledge, Skills and Abilities required at this le vel include knowledge of methods and technique s of medical re co rds maintenance; of applicable federal and state laws and agency and facility policies and pro cedures; of current classification systems; of report writing techniques; and of medical terminology.

Ability is required to maintain medical re co rds; to co de data to re co rds; to review medical re co rds for co mpleteness and accuracy; to prepare reports; to abstract information from re co rds and other patient data; to present information effectively; to establish and maintain effective working relationships with others; and to utilize personal co mputers.

Education and E x perience :

Education and E x perience requirements at this level co nsist of eligibility for accreditation with the American Health Information Manage ment Association as a Registered Health Information Technician (RHIT); or two years of e x perience working with patient re co rds in a medical setting such as a hospital, state institution, medical clinic or a physician’s office.

Special Requirements :

Based upon the duties and responsibilities assigned to the position being filled, a user agency may require accreditation with the American Health Information Manage ment Association as a Registered Health Technician (RHIT); or eligibility for registration as a Registered Health Information Administrator (RHIA).

Some agencies may have determined positions in this job family to be safety sensitive as defined by63 O.S. § 427.8.