How to Be Medical Records Clerk - Job Description, Skills, and Interview Questions

Jul 30, 2022 / 5 Minutes Read / By Albert

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When medical records clerks are not properly trained, it can lead to a number of negative consequences. These include higher risk of medical errors, longer processing times, and an increase in patient wait times. Without the right skills and knowledge, medical records clerks may not be able to accurately process paperwork in a timely manner, leading to delays and potentially even serious consequences for patients.

Furthermore, if there is a lack of oversight or communication between clerks and other healthcare staff, it can cause confusion and errors that can lead to potential liability for the organization. By investing in proper training for medical records clerks, organizations can ensure that their staff are equipped with the necessary knowledge and skills to accurately process medical records in a timely manner, thereby reducing risk and improving patient care.

Steps How to Become

Obtain a High School Diploma or GED. The first step to becoming a medical records clerk is to obtain a high school diploma or GED. This is a requirement for most entry-level positions in the medical records field.
Pursue Higher Education. Although a college degree is not always required for medical records clerk positions, many employers prefer applicants who have taken courses in medical coding, health information management, and medical terminology. Pursuing higher education can provide additional knowledge and skills that can be beneficial in this field.
Get Certified. Obtaining certification from either the American Health Information Management Association (AHIMA) or the National Healthcareer Association (NHA) is an excellent way to demonstrate skill and proficiency in the medical records field.
Gain Experience. Once the educational and certification requirements have been met, the next step is to gain experience in the field. Many employers prefer applicants with hands-on experience, so internships or volunteer opportunities at healthcare facilities are a good way to gain valuable experience in the medical records field.
Stay Up-to-Date. Technology advances quickly in the healthcare field, so its important for medical records clerks to stay up-to-date on new technologies and procedures. Taking continuing education courses or attending workshops can help keep skills current and demonstrate commitment to the field.

Maintaining a skilled and competent medical records clerk requires dedication and a comprehensive understanding of the job. The job includes responsibilities such as organizing records, filing documentation, verifying patient information, and processing requests for medical records. To be successful in this position, one needs to have an aptitude for organization and accuracy, as well as a good grasp of medical terminology.

medical records clerks need to stay up to date on the latest data-entry technology, legal requirements, and standards related to medical records management. By having a mastery of these skills, medical records clerks can ensure accuracy and efficiency when managing patient records, which leads to improved patient care.

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Job Description

Prepare and maintain patient medical records in accordance with established laws and regulations.
Verify accuracy of patient information, including patient history, diagnoses, test results, treatments and medications.
Prepare correspondence, reports, and other documents related to patient records.
Retrieve and file medical records as requested by physicians, nurses and other healthcare professionals.
Monitor patient information for completeness and accuracy.
Ensure the security and confidentiality of all patient records.
Respond to inquiries regarding patient medical records and release information to authorized personnel.
Scan patient medical records into electronic health record systems (EHR).
Make photocopies of patient medical records for authorized personnel.
Maintain filing systems for patient medical records.

Skills and Competencies to Have

Knowledge of medical terminology and coding
Ability to maintain patient confidentiality
Excellent organizational skills
Computer literacy and experience utilizing electronic medical records (EMR) systems
Solid understanding of HIPAA regulations
Ability to accurately enter, update, and retrieve patient information
Excellent communication skills
Ability to work independently and as part of a team
Ability to prioritize tasks and manage multiple projects simultaneously
Excellent customer service skills

Organizational skills are the most important skill for a medical records clerk. This is because medical records clerks are responsible for the accurate and timely maintenance of patient medical records. They must be able to organize and manage large amounts of data, such as patient histories, medication information, lab results, and medical insurance information.

they must keep track of changes in patient information and update the records accordingly. Without strong organizational skills, medical records clerks would not be able to properly manage these records, leading to errors and complications in patient care. As such, having a well-developed sense of organization is essential for anyone working in the medical records field.

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Frequent Interview Questions

How familiar are you with medical terminology and coding systems?
What experience do you have working with medical records databases?
Do you have experience working with Electronic Health Records (EHR) systems?
How comfortable are you working with a computer and basic software programs?
What methods do you utilize to ensure accuracy in data entry?
Describe a time you encountered a problem in medical record keeping and how you solved it.
Are you familiar with HIPAA regulations?
What strategies do you use to stay organized when managing multiple records?
Do you have experience dealing with confidential information?
How do you handle a situation when a patient requests access to their medical records?

Common Tools in Industry

Electronic Health Records (EHR) Software. This software allows medical records clerks to store and manage patient records digitally. (e. g. Epic, Cerner, Meditech)
Scanning Software. This software enables medical records clerks to scan and digitize documents for easy storage and retrieval. (e. g. Adobe Acrobat, ScanSnap)
Data Entry Software. This software allows for efficient data entry of patient information into the EHR system. (e. g. MediSYS, MEDITECH SE)
Quality Assurance Software. This software is used to ensure accuracy when entering patient information into the EHR system. (e. g. Sentry Data Systems, Logical Quality Assurance)
Document Management Software. This software is used to store, organize, and access patient documents in a secure and organized manner. (e. g. DocuWare, Laserfiche)

Professional Organizations to Know

American Health Information Management Association (AHIMA)
American Medical Records Association (AMRA)
National Association for Health Information Technology (NAHIT)
Healthcare Information and Management Systems Society (HIMSS)
American Academy of Professional Coders (AAPC)
American Medical Billing Association (AMBA)
National Alliance for Health Information Technology (NAHIT)
American Medical Informatics Association (AMIA)
Association of Medical Directors of Information Systems (AMDIS)
National Electronic Health Records Association (NEHRA)

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Common Important Terms

Medical Coding. The process of assigning alphanumeric codes to medical diagnoses and treatments to facilitate the billing process.
Clinical Documentation. A detailed, accurate record of a patient's history, diagnosis, treatments, and progress.
Electronic Health Record (EHR). A digital version of a patient's paper-based medical record that is accessible to authorized healthcare providers.
Health Information Management (HIM). The practice of collecting, storing, and managing the transfer of healthcare data to ensure accuracy and accessibility.
Release of Information (ROI). The process of authorizing the release of a patient's medical records to a third party.
HIPAA Compliance. The set of regulations established by the U. S. Department of Health and Human Services to protect the privacy and security of protected health information (PHI).

Frequently Asked Questions

What is the job of a Medical Records Clerk?

A Medical Records Clerk is responsible for maintaining patient information in a secure, accurate, and organized manner to ensure that confidential medical information is properly documented and stored.

What skills are required to be a successful Medical Records Clerk?

Successful Medical Records Clerks must have strong organizational skills, excellent attention to detail, and the ability to maintain confidentiality of sensitive information. Additionally, basic computer skills and knowledge of medical terminology are beneficial.

What are some of the duties of a Medical Records Clerk?

The primary duties of a Medical Records Clerk include filing and organizing medical records, updating patient information in databases, ensuring accuracy of data, and responding to requests for medical records. They may also be responsible for releasing information to authorized personnel.

How do Medical Records Clerks protect patient information?

Medical Records Clerks protect patient information by following strict data security protocols and procedures, such as following HIPAA guidelines and locking away confidential files. Additionally, they are responsible for verifying the accuracy of patient data before it is stored.

What qualifications are needed to become a Medical Records Clerk?

Generally, most employers require a high school diploma or equivalent for entry-level positions. Additionally, experience in a medical office setting or related field may be beneficial.