What a medical records specialist really does
You keep the patient record complete, correct and private, and you are the one who says no when someone asks for records they should not get.
FieldHealth
Preparation (O*NET Job Zone)Medium preparation needed
What the work involves
What fills a typical week for medical records specialists, built from O*NET occupation data.
- Work a queue of release of information requests from patients, lawyers, insurers and other providers
- Review discharged charts for missing signatures, documents and conflicting information
- Send queries to physicians when documentation is unclear
- Abstract and code diagnoses and procedures, and assign DRGs where coding is part of the role
- Scan, index and merge records so every document lands in the right patient chart
- Answer calls and emails from clinicians, billing and patients about records
What the days are like
What people in the job know
- Exactness is the job. Small errors in a record or a code ripple into care, billing and legal problems. Importance of being exact or accurate: 78% extremely important (O*NET Work Context)
- Much of the work is repetitive, and that is by design. Importance of repeating same tasks: 48% extremely important, 43% very important (O*NET Work Context)
- Deadlines hit weekly, often tied to billing or legal timelines, rather than minute to minute emergencies. Time pressure: 37% every day, 53% once a week or more (O*NET Work Context)
- It is more social than people expect, with constant calls, emails and questions from staff. Telephone conversations: 79% every day; E-mail: 88% every day; Face-to-face discussions: 89% every day (O*NET Work Context)
- Guarding privacy is the most important single task, above data entry or coding. Task rank 1: Protect the security of medical records to ensure that confidentiality is maintained, importance 95 (O*NET)
How people get into it
O*NET respondents report a high school diploma (52%) or a postsecondary certificate (22%) for new hires, and the role sits in Job Zone 3, meaning a year or two of training and experience. Many people complete a coding certificate and earn a credential such as AHIMA's CCA or CCS or AAPC's CPC; the RHIT credential requires an associate degree from a CAHIIM accredited health information program.
The Firstday trial, easy to hard
Three simulated tasks with AI coworkers who message you, react to your work and coach with questions. Nobody scores you.
What the trial can't show: This trial does not cover scanning and handling paper records, learning a full code set such as ICD-10-CM and ICD-10-PCS, the long stretches of focused solo work at a screen, or production quotas measured over months. It covers release decisions, chart review, physician queries and a simplified coding and DRG task. You work as a new specialist under an HIM supervisor; all patients, providers and requests are fictional, and coding rules are simplified for training.
Reading about it is one thing.
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Job details on this page are built from O*NET OnLine, 29-2072.00. This page includes information from the O*NET 31.0 Database by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA). Used under the CC BY 4.0 license. O*NET® is a trademark of USDOL/ETA.