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Medical Records Clerk Resume: Winning Examples for 2024

When it comes to landing a job as a Medical Records Clerk, having a winning resume is absolutely crucial. A resume that showcases your skills, experience, and education can be the difference between landing an interview or being passed over entirely. But first, let’s define what exactly a Medical Records Clerk does.

Definition of a Medical Records Clerk Role

A Medical Records Clerk is responsible for maintaining and organizing patient records in healthcare facilities. They ensure that records are accurate, up-to-date, and easily accessible to healthcare professionals when needed. This includes tasks such as:

• Filing and retrieving records
• Entering data into electronic health systems
• Ensuring records are secure and confidential
• Communicating with other healthcare professionals about patient records

Importance of having a Winning Resume

As a Medical Records Clerk, having a well-crafted resume is crucial to catching the attention of potential employers. By highlighting your qualifications and relevant experience, a winning resume can help you stand out from the competition and secure an interview. Some things to consider when crafting your resume include:

• Highlighting your education and any relevant certifications or training
• Demonstrating your proficiency with electronic health systems and medical terminology
• Showcasing your attention to detail and ability to maintain accurate records
• Emphasizing your communication and teamwork skills

Ultimately, a winning resume can help you land the job of your dreams as a Medical Records Clerk. So take the time to craft a strong and compelling resume that showcases your unique skills and abilities.

Key Responsibilities of a Medical Records Clerk

If you are considering a career in medical administration, working as a medical records clerk may be a great choice. In this section, we will discuss the key responsibilities of this role, the competencies required to excel, and how you can showcase these competencies on your resume.

Role of a Medical Records Clerk

Medical records clerks are responsible for managing patient files and keeping them organized. They handle patient information such as medical histories, lab results, and radiology reports. They also ensure that all information is up-to-date and accurate, and that patient confidentiality is maintained.

Other responsibilities of a medical records clerk include:

• Preparing patient folders for new admissions
• Retrieving patient files and records for healthcare providers and authorized personnel
• Entering patient information into electronic medical record (EMR) systems
• Monitoring and tracking patient files to ensure they are complete
• Purging and archiving files according to state and federal regulations

Key Competencies Required

To be an effective medical records clerk, there are several competencies that you should possess. These include:

• Attention to Detail: Medical records clerks need to be meticulous and detail-oriented as they deal with sensitive patient information that must be accurate and complete.
• Organizational Skills: This role requires managing a large volume of patient files, which requires strong organizational skills to ensure that everything is easily accessible and properly labeled.
• Technology Proficiency: Medical records clerks must be comfortable working with electronic medical record (EMR) systems and other healthcare technology.
• Communication Skills: This role requires regularly communicating with healthcare providers and other staff, so strong verbal and written communication skills are essential.

Showcasing Competencies on Your Resume

When applying for a medical records clerk position, it is important to showcase your competencies on your resume. Here are some ways you can do this:

• Create a skills section: List your competencies in a separate section at the top of your resume.
• Use specific examples: Highlight specific examples of how you have utilized your competencies. For example, if you have strong attention to detail, mention how you have maintained accurate and complete patient files.
• Quantify your achievements: If possible, quantify your achievements in your previous roles. For example, mention the number of patient files you managed or the amount of time you spent entering patient information into EMR systems.

Medical records clerks play a vital role in healthcare administration. To excel in this role, you must possess attention to detail, organizational skills, technology proficiency, and communication skills. By showcasing your competencies on your resume, you can increase your chances of landing a job as a medical records clerk.

Elements of a Great Medical Records Clerk Resume

When it comes to creating a winning resume for a Medical Records Clerk position, it’s important to include the right sections and key elements. Here are some guidelines to help you create a compelling resume that showcases your skills, experience, and qualifications.

Sections of a Good Medical Records Clerk Resume

Contact Information:  This should be placed at the top of your resume and include your name, address, phone number, and email address.

Objective Statement/Professional Summary:  This section should also be placed at the top of the resume and highlight your career goals, skills, and qualifications that are relevant to the job you are applying for.

Experience:  This section should list your work experience, starting with your most recent job. Include your job title, company name, location, employment dates, and a list of your responsibilities and accomplishments.

Education:  This section should list your educational credentials, including the name of the school, degree, major/minor, and graduation date.

Skills:  In this section, list your relevant technical and soft skills, such as proficiency in medical coding systems, computer software, and communication.

Certifications/Licenses:  If you have any relevant certifications or licenses, list them in this section.

Key Elements in the Medical Records Clerk Resume

Conciseness:  Keep your resume concise and to the point, highlighting your most important skills and qualifications.

Accuracy and Detail:  Attention to detail is critical in medical records management, so make sure your resume is free of errors and includes specific examples of your experience and accomplishments.

Relevance:  Make sure your resume is relevant to the job you are applying for by tailoring it to the specific job description and requirements.

Quantifiable Results:  Whenever possible, highlight specific results you achieved in previous roles, such as improvements in efficiency, cost savings, or increased accuracy.

Keywords:  Incorporate important keywords from the job description throughout your resume to ensure that it passes through applicant tracking systems.

A Brief Discussion on the right format and style for a Medical Records Clerk Resume

The right format and style for your Medical Records Clerk resume will depend on your personal preferences, the company’s application guidelines, and the specific job requirements. However, here are some general guidelines to follow:

Professional Font:  Choose a professional font, such as Times New Roman, Arial, or Calibri, and stick to 10-12 point size.

Use Bullet Points:  Use bullet points to clearly list your responsibilities and achievements, making it easy for recruiters to scan and understand your experience.

Keep It Simple yet Visually Appealing:  While your resume should be easy to read, you can still make it visually appealing with a simple layout, strategic use of bold and italic fonts, and with the right use of white space.

Essential Skills for a Medical Records Clerk

A medical records clerk plays a crucial role in maintaining the accuracy and organization of medical records. In order to excel in this position, certain essential hard and soft skills are necessary.

Hard Skills

• Knowledge of medical terminology:  A medical records clerk must be familiar with medical terms in order to accurately categorize and file patient records.
• Attention to detail:  This skill is critical in maintaining the accuracy of medical records. A small mistake can have serious consequences for a patient’s health.
• Computer skills:  As electronic medical record systems become more common, proficiency in computer skills is essential for a medical records clerk.
• Familiarity with medical record laws and regulations:  A medical records clerk must understand the legal requirements surrounding medical records, including HIPAA regulations and laws governing the retention and release of medical records.

Soft Skills

• Communication skills:  A medical records clerk must be able to communicate effectively with other healthcare professionals, including doctors, nurses, and administrative staff.
• Time management skills:  With the volume of patient records a medical records clerk handles on a daily basis, it’s important to be able to manage time effectively.
• Organizational skills:  Keeping patient records organized is key to ensuring patient safety and maintaining compliance with legal requirements.
• Customer service orientation:  While a medical records clerk’s primary responsibility is record-keeping, they may also interact with patients and their families. A customer-service oriented approach is important in these interactions.

Highlighting Skills on a Medical Records Clerk Resume

When writing a resume for a medical records clerk position, it’s important to highlight both hard and soft skills. A few strategies for doing this include:

• Customizing the resume:  Tailor the resume to the specific position by including keywords from the job description. This helps emphasize the skills that the employer is looking for.
• Including a skills summary:  A brief summary of skills can appear at the top of the resume, giving the employer an at-a-glance view of key qualifications.
• Including achievements:  Highlighting achievements that demonstrate key skills, such as reducing record errors or streamlining filing processes, helps to show the employer the value a candidate brings to the role.

Quantifying Accomplishments

Quantifying accomplishments on a medical records clerk resume helps to demonstrate the impact a candidate has had in previous roles. A few possible approaches to quantification include:

• Using numbers to describe accomplishments:  For example, “Implemented a new record-keeping system that reduced errors by 30%.”
• Describing the impact on patient care:  Emphasizing the importance of accurate record-keeping to patient safety, such as “Ensured medical records were accurately filed, resulting in no missed doses of medication.”
• Listing key responsibilities and accomplishments:  Providing a comprehensive list of responsibilities and outlining accomplishments in each area can help to highlight the scope of a candidate’s work.

Medical Records Clerk Resume Example

As you write your medical records clerk resume, you must ensure that you highlight your key skills and expertise. Here is a detailed example of a well-crafted medical records clerk resume that should inspire you.

Personal Information Section

This section should include your name, address, phone number, and email address.

Summary Section

This is a brief section that should highlight your skills and expertise as a medical records clerk. Limit this section to a maximum of three to four sentences.

Professional Experience Section

This section should list your professional experience starting with the most recent experience. It should highlight the following:

• The name and location of the company you worked for
• Your job title
• The period of employment, i.e., start and end dates
• A brief description of your roles and responsibilities, preferably in bullet points

Education Section

This section should list your academic achievements, including:

• The name of the institution you attended
• The degree or certificate you earned
• The period of attendance, i.e., start and end dates

Skills Section

This section should highlight your relevant skills, including:

• Strong written and verbal communication skills
• Expertise in using electronic medical records systems
• Knowledge of medical terminology
• Attention to detail
• Ability to work independently and as a team player

In the above resume example, the medical records clerk has highlighted their key skills in the skills section. They have also emphasized their experience in electronic medical records and highlight their attention to detail and communication skills in their professional experience section. This shows that the applicant has the necessary skills to thrive in the role of a medical records clerk.

When crafting your medical records clerk resume, ensure that you highlight your key skills and experience. Use bullet points and be as specific as possible in describing your roles and responsibilities in the professional experience section. Also, highlight your academic achievements and soft skills in the education and skills section, respectively.

Using Keywords in Medical Records Clerk Resume

As hiring managers receive numerous resumes for a Medical Records Clerk position, using the right keywords in your resume is crucial to catching their attention. By incorporating keywords into your resume, you can effectively showcase your skills and qualifications and increase your chances of getting noticed.

Identifying the Right Keywords for a Medical Records Clerk Resume

The first step in using keywords to improve your Medical Records Clerk resume is identifying the keywords relevant to the job you are applying for. These keywords are typically the skills, qualifications, and requirements that the job posting highlights. You can also refer to other similar job postings and job descriptions for Medical Records Clerk positions to gain a better understanding of the common keywords used in the field.

In general, keywords for a Medical Records Clerk Resume usually include:

• Electronic Health Records (EHR) software
• Medical Terminology
• HIPAA Compliance

Additionally, look for other skills and certifications required for the job such as CMA (Certified Medical Assistant) or RHIT (Registered Health Information Technician).

How to Use Keywords to Increase the Chances of Getting Noticed

Once you have identified the right keywords for the Medical Records Clerk position, it is essential to incorporate them properly into your resume. Here are a few tips on how to use keywords to maximize your chances of getting noticed:

• Use the important keywords multiple times throughout the resume. Include them in the summary, experience, education, and skill sections.
• Don’t overuse the keywords as that will backfire. Make sure they are well-inserted and sound natural in the context.
• Be specific about the tasks you accomplished using the specific keywords. Use action verbs, such as organized, filed, sorted so that it is easy to understand the impact of the keywords in the job.
• Use keywords only when you have relevant experience and accomplishments to back them up. Avoid mentioning random words that are unrelated to your work experience.

A few Keywords to Use in Your Medical Records Clerk Resume

Here are a few examples of keywords that you can use in your Medical Records Clerk Resume:

• Electronic Health Records (EHR) software: Proficient in managing patient data through Electronic Health Records (EHR) systems such as EPIC, Allscripts, and Cerner.
• Medical Terminology: Broad knowledge of medical terminologies such as ICD-10 and CPT codes, which have helped in clear documentation of patient procedures and diagnoses.
• HIPAA Compliance: Well acquainted with the HIPAA compliance regulations to uphold patient confidentiality and ensure data privacy in all administrative and clinical duties.
• Data Entry: Experienced in data entry procedures, such as scanning, indexing, and abstracting medical documents, which resulted in efficient tracking and retrieval of patient data.

Using the right keywords in your Medical Records Clerk Resume can be a powerful way to get noticed by hiring managers.

Keeping the Medical Records Clerk Resume Simple

When it comes to creating a winning Medical Records Clerk Resume, one of the most important aspects to consider is simplicity. A simple resume is crucial because it enables hiring managers to quickly and easily identify your qualifications without the need to sift through a mountain of information.

Explaining Why Simplicity is Important

Hiring managers have limited time to review resumes, and simplicity can significantly improve a candidate’s chances of being considered for a position. A simple Medical Records Clerk Resume allows hiring managers to scan your qualifications with ease and quickly determine whether you are a good match for the position. Moreover, a simple resume can also make a positive first impression and show that you are organized, concise, and professional.

Exploring Ways to Make a Resume Simple

Making a resume simple does not mean compromising on its quality. Instead, it’s about presenting key information in a way that is easy to read and comprehend. Here are some tips to help make your Medical Records Clerk Resume simple and effective:

• Keep it concise: Focus on including relevant information only and keeping your resume to one or two pages.
• Use bullet points: Bullet points help to break up text, making your resume visually appealing and easier to read.
• Use keywords: Incorporate keywords from the job description and industry to help your resume stand out to the hiring manager and pass through applicant tracking systems (ATS).
• Choose a readable font: Select a font that is easy to read, such as Arial, Calibri, or Times New Roman, and keep font size at 10-12 points.
• Avoid jargon: Avoid using technical jargon or acronyms that may not be universally understood.

Using Online Tools to Assess the Readability of the Medical Records Clerk Resume

To make sure that your Medical Records Clerk Resume is both simple and easy to read, it’s important to use online tools to assess its readability. These tools analyze your resume and provide a readability score, indicating how easy it is to read for the average person.

Some of the popular online readability tools include Grammarly, Hemingway, and Readable. These websites analyze your resume and provide feedback on areas that need improvement, such as sentence complexity, unnecessary jargon, and use of passive voice.

By keeping your Medical Records Clerk Resume simple and easy to read, you can significantly increase your chances of catching the attention of hiring managers and ultimately land your dream job.

How to Tailor a Medical Records Clerk Resume to the Job Description

When applying for a job, it is crucial to understand the importance of tailoring your resume to fit the specific job description. Hiring managers receive numerous resumes for every open position, so customizing your application materials is essential to make your resume stand out from the rest.

As a medical records clerk, you need to demonstrate that you meet the qualifications and requirements of the job you are applying for. To do this effectively, you must tailor your resume to match the job description. Here are some tips on how to do that:

Understanding the Importance of Tailoring Resumes for the Job

It is essential to understand that no two jobs are the same, and neither should your resume be. Every job has its unique requirements, so your resume needs to showcase your qualifications that make you an excellent candidate for the open position.

You must know the job description inside and out, including the specific skills and qualifications that the employer is looking for in an ideal candidate. Take note of the keywords and phrases used in the job posting and incorporate them throughout your resume.

Discussing How to Tailor the Resume to Each Job

Start by reviewing your resume and analyzing how your skills, experiences, and qualifications match up with the job requirements. Then customize your resume to fit the job description, highlighting the most relevant skills and experiences.

Here are some points to keep in mind when tailoring your medical records clerk resume:

Use a matching format that reflects the company’s culture and values.

Emphasize your transferable skills and showcase how they could be beneficial to the position.

Quantify your accomplishments and provide metrics to showcase the impact of your work.

Mention any relevant coursework or training that relates to the job.

Use keywords from the job description to help your resume pass through applicant tracking systems (ATS).

Including Examples of How This Can be Done

To illustrate the point better, here are some examples of how you can tailor your resume to a medical records clerk job description:

Job Description: “Looking for a medical records clerk with experience in electronic medical records (EMR) software.”

Tailored Resume Skills and Experiences:

• Advanced knowledge of EMR software.
• Experience in training new hires on EMR software.
• Developed an efficient system for tracking patient records using EMR software.

Job Description: “Seeking a detail-oriented medical records clerk with experience in handling sensitive information and maintaining confidentiality.”

• Proven track record of maintaining confidentiality in storing, retrieving, and releasing medical records.
• Developed a system for maintaining accurate and up-to-date patient files.
• Attended data privacy and security courses to ensure compliance with HIPAA regulations.

Tailoring your medical records clerk resume can significantly increase your chances of landing an interview.

Cover Letter for a Medical Records Clerk

When it comes to applying for a job, a well-crafted cover letter can make a significant difference. Your cover letter is often the first thing an employer will see, so it’s essential to make a good first impression. In this section, we will discuss how to write an effective cover letter and the different types of cover letters. We will also guide you on what to include in a cover letter for a Medical Records Clerk.

How to write an Effective Cover Letter

An effective cover letter should showcase your skills, qualifications, and enthusiasm for the job. It should be concise, professional, and compelling. Here are some tips on how to write an effective cover letter:

Start with a strong opening statement: Begin your letter with a sentence that captures the hiring manager’s attention and highlights your interest in the job.

Highlight your skills and experience: Focus on your skills and experience that are most relevant to the job. Use specific examples to illustrate your strengths.

Show enthusiasm for the job: Let the hiring manager know why you are excited about the role and how you can contribute to the organization.

Keep it concise: Your cover letter should be no more than one page. Keep your sentences short and to the point.

Tailor your letter to the job: Customize your cover letter to the job you are applying for. Use keywords and phrases from the job description.

Discussing the Different Types of Cover Letters

There are three main types of cover letters: application letters, prospecting letters, and networking letters.

Application letters: These are used to apply for a specific job opening. They should focus on your qualifications and experience relevant to the job.

Prospecting letters: These are sent to companies inquiring about possible job openings. They should showcase your skills and experience and express your interest in working for the company.

Networking letters: These are sent to people in your professional network, asking for job leads or referrals. They should be brief and to the point.

What to include in a Cover Letter for a Medical Records Clerk

When writing a cover letter for a Medical Records Clerk job, there are specific things you should include:

Your relevant experience: Highlight any experience you have in medical records management, including specific software or systems you have used.

Your qualifications: Mention any education or certification related to the job.

Your attention to detail: Medical record keeping requires precision and accuracy, so emphasize your attention to detail.

Your abilities to work with patients and healthcare providers: Being able to communicate effectively with healthcare providers and patients is critical in this role, so highlight your abilities in this area.

Your enthusiasm for the job: Let the hiring manager know how excited you are about the opportunity and why you are the best fit for the job.

Tips for Writing an Effective Medical Records Clerk Resume

Are you hoping to land a job as a medical records clerk? If so, your resume will play a significant role in your job search. A well-crafted resume can open doors and lead to interviews, while a poorly written one can quickly end your chances of getting your dream job. In this section, we’ll explore various tips to help you craft a winning medical records clerk resume that sets you apart from other candidates.

Tailor your resume to the job description: Medical records clerk positions vary in their requirements, so it’s essential to customize your resume to match the specific job posting. Look for keywords and phrases in the job description and use them in your resume to help your application get past the applicant tracking system (ATS) and into the hands of the hiring manager.

Highlight your relevant experience: In the medical records field, employers will be looking for candidates who have experience managing medical records, understanding medical terminology, and working with electronic medical record systems. Make sure to highlight these qualifications prominently in your resume.

Emphasize your attention to detail: The role of a medical records clerk requires a high level of accuracy and attention to detail. Emphasize your attention to detail in your resume by including examples of how you’ve ensured the accuracy of medical records in previous roles.

Use bullet points to keep it concise: Medical records clerks need to be organized and efficient, and your resume should reflect those qualities. Use bullet points to keep your resume concise and easy to read, focusing on specific accomplishments and qualifications.

Common Mistakes to Avoid When Writing a Medical Records Clerk Resume

Failing to proofread: Attention to detail is critical in the medical records field, and a resume that’s riddled with typos or grammatical errors can quickly disqualify you from a job. Always proofread your resume carefully, and consider having a friend or mentor review it as well.

Using generic language: Avoid using generic language in your medical records clerk resume. Instead, customize your resume with specific keywords and phrases that are relevant to the job and highlight your unique qualifications and accomplishments.

Omitting relevant experience: Make sure to include any relevant experience you have, even if it’s not in the medical records field specifically. For example, if you’ve worked with electronic medical record systems in a different context, make sure to include that experience on your resume.

Overcomplicating your formatting: While you want your resume to stand out, don’t overcomplicate the formatting. Stick to a clean, easy-to-read format, and avoid excessive use of bold, italicized, or fancy fonts.

By following these tips and avoiding common mistakes, you’ll be well on your way to creating a winning medical records clerk resume. Good luck in your job search!

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EMR Specialist Resume Samples

An EMR Specialist is an electronic medical record Specialist who undertakes responsibility for analyzing designs, developing and implementing electronic medical record systems . The job duties are mentioned on the EMR Specialist Resume as – ensuring the proper usage of the systems, implementing upgrades, and designing ways to become more efficient; allowing employees of the hospital to store, access, and update patient’s health records electronically; facilitating the exchange of information among medical organizations; overseeing the implementation and support of the systems, and upgrading new systems .

A bachelor’s degree is a typical requirement needed to work in this capacity. Besides, the following skills are as well needed – familiarity with EHR and other similar systems; strong communication skills, the ability to work both independently and as a member of the team; and record management skills. Qualifications in information technology or health information management are advantageous.

• Resume Samples
• EMR Specialist

EMR Specialist Resume

Headline : To take a challenging role on the IST team as an IST Analyst and give an efficient and effective solutions that will help the organization to achieve the best solution in business and ultimately improve patient care documentation.Clearly communicates complex system design and/or workflow processes to end users in a manner that is accessible to various levels of technological understanding. Collaborating with EMR Analysts to better understand the potential and/or limitations of system design.

Skills : Microsoft Office, Apple Products, Carpentry.

Description :

• Responsible for providing and maintaining accurate and complete patient records.
• Position required attention to detail, ability to work both independently and within a team, and strong communication skills as well as sort, scan, and file a variety of medical records and information such as admission slips, laboratory and pathology reports, operative notes, and discharge summaries into electronic patient medical records in appropriate sections.
• Entails trained doctors and their staff on the EMR module, developing handouts and letters based on the practice's needs, testing the software, working with the various vendors (GE, Index logic) to ensure programs are running as efficient as they should be and bringing new ideas and features to the Electronic Medical Records Module.
• Created, organized, and set up an information center for manuals and schematics.
• In charged of maintaining OCR (Optical Character Recognition software-Indexlogic) as well as being in charge of the pin-safe (remote access) program.
• Put in charge of managing the patient portal alongside with the individual who manages the secure messaging program.
• Processed medical batch files, retrieve and sort through images of various patient encounters, review electronic records for accuracy, coding to.

Summary : To use my high energy and self-motivating personality to gain a position as a Electronic Medical Records Specialist where I can increase overall company productivity and profitability by building, updating and maintaining Clinical applications and improving workflow through education and training. Approaching is to focus on proper documentation, coding, and corporate compliance while using an open door attitude that offers a safe work environment.

Skills : Medical Records, EMR.

• Designed programming and development of clinical and procedural templates.
• Insured proper documentation and billing for a 19 location-5 state medical practice.
• Added and trained new users.
• Established standard operating procedures for every aspect of patient flow from check-in to scheduling.
• Processed service, claimed and insurance analysis reports.
• Scanned charts and performed quality review on patient charts.
• Downloaded pull lists of charts from websites and downloaded charts to pdf folders I also worked as a Team Lead(Night Time Supervisor).

Headline : Seeking employment with a company where I can grow professionally and personally, & Executing EMR Help tasks as assigned and prioritizes incoming requests as outlined by EMR leadership, Providing Dragon support to new and existing users, Updating and/or maintaining basic system settings in EpicCare Ambulatory under the guidance of EMR analysts.

Skills : Microsoft Office, Epic, AthenaNet, Electronic Medical Records.

• Provided expert subject matter knowledge on EMR software, clinical operations and workflow.
• Reviewed existing paper documentation and develop electronic templates and documents using EMR tools.
• Recommended software enhancements based on evaluation and feedback from end users.
• Delivered and administered training program to end user as required.
• Helped to resolve critical problems related to implementation.
• Managed communication between clinic staff, physicians, and management.
• Provided training and support to Medical Doctors and Registered Nurses on ambulatory Electronic Medical Record (EMR) software.

Headline : Position as an EMR Specialist where I can utilize the expertise in the field of medical assistance and administrative task to achieve the uppermost level of caring for patients while maximizing the efficiency of your facility. Experienced in both private physician office and large medical group settings.

Skills : Centricity (4 years), Allscript/Touch chart/Citrix.

• Mastered the process of collecting, processing, and managing patient medical records in digital formats using specialized software.
• Organized patient information to enable remote access for doctors as well as patients themselves thereby improving access to information.
• Scheduled and facilitated classroom sessions for 20-60 medical staff members per class.
• Recognized for providing at the arm and one-on-one support to clinical positions at all locations.
• Demonstrated expertise as Informatics trainer tasked with training nursing and physician staff in the use of Cerner Power Chart system and Dragon Medical Software.
• Created training content, devised methodology, and conducted knowledge transfer sessions for 2500+ participants over five months.
• Tirelessly worked towards conceptualizing, organizing, and implementing on-site and remote training sessions for nurses on the basics of electronic medical information recording systems.

Headline : A highly talented EMR Specialist with experience in performing routing patient screening, additional technical supportive services, medical clerical duties and other duties, as assigned; collecting, handling, and processing patients' laboratory specimens, including phlebotomy and performing routine in-house laboratory tests; administering medications to patients on specific orders from a provider.

Skills : Medical Records, Administrative.

• Ensured compliance with state regulations and standards by meticulously assessing system performance and conducting usage audits.
• Initiated the use of Moodle as an online training resource thereby increasing efficiency and saving time.
• Developed workflow redesign which included modifications to policies and procedures.
• Conducted quantitative and qualitative analyses for project teams, clients, and department management.
• Gave the agents their assignments, kept up with payroll on each agent that I was in charge of, did audits on what the agents did, kept spreadsheets on the number of charts done per agent per shift, and per hour, spreadsheets on the totals of charts that passed audits, and charts of audits that did not pass the audit.
• Coordinated with CIS and project managers to facilitate Epic hospital EMR trainings and Go-Live support for Providence Health & Services hospitals in .
• Analyzed, certified, and notarized records prior to scanning.

Objective : EMR Specialist with 5 years of experience in Maintaining Epic training environments by building patients, appointments and relevant content as necessary. Performing testing of each training environment prior to distribution to other departments. Delivering optimization training as updates occur, and provides one-on-one efficiency training as requested.

Skills : Training, Delivering, EPIC Training.

• Processed requests for release of medical records following departmental procedures and documenting the date of the release and scan the request.
• Scanned loose material and documentation that is received electronically accurately insert the documents into the repository in the patients EMR .
• Used computer software systems and data bases to preform quality assurance audits.
• Implemented new systems or updates.
• Supported and guided the EMR
• Led quality assurance testing.
• Created business requirements & gap analysis for new systems or updates.

Headline : EMR Specialist with 4 years of experience in Designing eLearning materials, demonstrations, and simulations using content creation software (Captivate, Articulate, etc.) as outlined by the EMR Management team. Updating and maintaining EMR SharePoint site with tip sheets, FAQs or other reference material. Leading classroom training by presenting training material clearly and with confidence.

Skills : Leadership, Classroom Assistant, e-Learning.

• Developed and implemented change management strategies.
• Helped manage projects and be a key resource for IT initiatives.
• Promoted technology adoption and helped support system onboarding.
• Understood the product in relation to other company products. 
• Understood the product life cycle from development through sales and customer support.
• Possessed sufficient fundamental proficiency to successfully demonstrate knowledge of Incident Tracking and Problem Reporting in practical applications of moderate difficulty. 
• Wrote problem reports that contain all of the necessary information for clear, non-antagonistic communication to those responsible for fixing problems. 

Objective : EMR Specialist is Attending meetings, participates in workgroups and/or serves on committees. Demonstrating enthusiasm and professionalism when collaborating with team members and other employees. Participating in system upgrades through analysis, testing and development of documentation to support workflows and procedures.

Skills : Documentational Skills, Testing, Supportive Skills.

• Effectively explained how to reproduce and analyze errors, as well as identify the type of error including coding, design issue and hardware. 
• Made simple suggestions for correction.
• Demonstrated the ability to apply changes or develop new functions related to this topic.
• Critically evaluated the customer implications of technological changes.
• Interpreted business data as it applies to this topic.
• Demonstrated ability to realistically anticipate resource needs, identify discrete tasks, set priorities, define dependencies, schedule activities, meet deadlines, and organize work for basic plans. 
• Appropriately matched equipment to task demands. 

Objective : EMR Specialist is Coordinating EMR Help Desk activities to ensure end user requests for help, training or optimization are addressed by the appropriate members of the EMR team. Working closely with end users to identify training opportunities and develops material to reinforce best practices as outlined by EMR Management team.

Skills : EMR Management Team, Help Desk, Training.

• Demonstrated ability to break down work into manageable and measurable units. 
• Accepted changes to plans with minimal disruption and loss of productivity. 
• Followed up to assure problems and issues are resolved, and monitors plan progress effectively.
• Delivered distinctively personalized care.
• Improved the health care of individuals and communities regionally, nationally and internationally.
• Provided transformative learning programs.
• Supported compelling discoveries.

Objective : As an EMR Specialist position responsible for Calling patients when insurance coverage cannot be verified or is inactive. Answering and transferring calls from phone queue. Providing backup support to the Insurance Verification Specialists by contacting patients' insurance company to verify coverage and contacting patients when insurance coverage is not verified for office appointments.

Skills : Insurance Management, Supervising Skills, Processing Assistant.

• Worked with UW Specialty Clinics to identify pertinent patient information to assist in the scheduling, ambulatory access, and pre-visit planning processes.
• Worked with the internal HIM and other UW teams to optimize workflows around record gathering and abstraction, streamlining the prior authorization process, and optimizing use of electronic medical records.
• Utilized EMR (electronic medical record) functionalities and Access Database to coordinate record retrieval from external providers.
• Accessed online insurance verification portals to validate patient insurance coverage prior to each patient visit.
• Contacted insurance provider when benefits cannot be verified online.
• Obtained authorization for rehabilitative services visits as required by insurance provider.
• Added, entered or updated patient benefit information into the EMR in a timely and accurate manner.

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Electronic Medical Records EMR EHR Resume & LinkedIn Profile Writing Samples

Learn about electronic medical records emr ehr resume and linkedin profile examples that add more job interviews..

Updated 05/09/24. Utilize top-tier EMR/EHR sales, tech, and operations resume and LinkedIn samples on our webpage.

Tailored for professionals in electronic medical records field, our resources highlight expertise in sales, product development, healthcare tech implementation, hospital client relations, and HIPAA compliance. From sales strategies, telemetry integration to operations automation, our ATS-optimized templates equip you with the tools to excel in the digital healthcare landscape.

Utilize our free templates to articulate your EMR/EHR solutions capabilities, bridging healthcare records with technology. Craft a compelling profile with our tools and pave your way to success in the fast-evolving world of healthcare IT. Our guides show the modern layout and sections job recruiters expect: headline, summary, skills, keywords, work experience, education, and PMP certifications.

Electronic medical records resume example. Click to enlarge.

Electronic  medical records LinkedIn profile example. Click to enlarge.

ATS Friendly Resume Format Explained

Applicant tracking system (ATS) is software job recruiters use to automatically import, scan, filter, and rank resumes submitted when candidates upload them to job postings. ATS cannot read and process documents with fancy formats. A resume with tables, charts, images, two columns, boxes, headers, and footers, will likely be rejected by the ATS before a human sees it. Professional resumes use a simple, text-only format. LinkedIn is the place to add images, videos, articles, and other creative examples of your work.

Electronic medical records resume layout job recruiters expect to see:

Format: use reverse-chronological work experience resume format. List your most recent job at the top.

Fonts: use narrow width fonts like Calibri or another sans-serf font like Arial

Heading font-size: 11 or 12-point size

Body text font-size: 10.5 is the standard resume font size, but 10 or 11 are acceptable.

Line spacing: prefer .5 between experiences, but 0 is acceptable.

Resume margins: .5 or .75 inches all around.

Dates: include year and month 01/202-07/2023.

File type: submitting a resume in Microsoft Word is acceptable. A PDF is not required.

Electronic medical records resume critical parts and sections:

Header: Your contact information.

Headline: One line that summarizes your skills and presumed new job goals

Biography: 5-8 sentence summary of your abilities and accomplishments.

Skills: add your skills that match the jobs you seek in common industry terminology.

Work Experience: your job scope and quantifiable achievements.

Education: degrees, certifications, and certificates.

Explore resume and LinkedIn profile examples for other career functions and industries here .

Learn more about our team, process, and top-rated results.

Medical Records Coordinator Resume Example & Writing Guide

Use this Medical Records Coordinator resume example and guide to improve your career and write a powerful resume that will separate you from the competition.

Medical records coordinators are the bridge between patients and their medical records. They’re tasked with ensuring that medical records are created, stored, and accessible when patients need them most.

If you’re passionate about helping others and want to work with huge amounts of data in a high-pressure environment, then you might be ready to make the jump into medical records. But before you can land that dream job, you need a resume that showcases your skills and experience in a way that will impress hiring managers.

Follow these tips and resume example to write a medical records coordinator resume that hiring managers will love.

Meticulous and compassionate medical records coordinator with more than 10 years of experience in the healthcare industry. Proven ability to manage and organize patient data while ensuring compliance with HIPAA regulations. Eager to utilize expertise in a position that allows for continued growth and development.

• Managed the flow of medical records through the department and ensured that all documentation is complete, accurate, legible, and timely.
• Provided training to new employees on EMR system functions including but not limited to charting procedures, searching for charts by patient name or ID number, etc.
• Assisted with audits as needed regarding compliance with regulations and guidelines related to confidentiality of health information.
• Maintained a high level of knowledge in HIPAA regulations and participated in ongoing education opportunities provided by vendor/hospital systems as well as hospital staff meetings.
• Participated in Quality Improvement activities such as data collection and analysis using appropriate tools (e.g., CPOE).
• Created a database of patient information, including medical history and insurance details to ensure accurate billing
• Ensured that all patients received the correct prescriptions by verifying orders with pharmacists before filling them
• Maintained confidentiality of patient records at all times; ensured HIPAA compliance through regular training
• Collaborated with physicians on treatment plans for each patient based on their individual needs and circumstances
• Scheduled appointments, verified insurance coverage and collected co-pays from patients upon check-in
• Managed the process of scanning and indexing medical records into the electronic health record system.
• Retrieved and assembled patient medical records for physician review and chart completion.
• Maintained the integrity of medical records by ensuring all records were complete, accurate, and filed in a timely manner.
• Certified Professional Coder (CPC)
• Certified Tumor Registrar (CTR)
• Certified Health Information Technician (CHIT)

Industry Knowledge: HIPAA, Faxing, Telephonic Communication, Electronic Medical Records, Electronic Health Records, Coding, Billing Technical Skills: Microsoft Office Suite, Windows, Medical Terminology, CPT, ICD-9, EHR, HIPAA Soft Skills: Communication, Teamwork, Attention to Detail, Problem Solving, Leadership

How to Write a Medical Records Coordinator Resume

Here’s how to write a medical records coordinator resume of your own.

Write Compelling Bullet Points

When you’re writing bullet points, it can be tempting to simply list your responsibilities. But that’s not enough to make a strong impression. Instead, you should use your bullet points to demonstrate your value by describing how you contributed to the organization.

For example, rather than saying you “managed patient records,” you could say that you “managed patient records for 15-physician practice, ensuring all records were up to date and accessible by all providers.”

The second bullet point paints a clearer picture of what exactly you did and how it helped the organization. And it also provides a quantifiable detail about the size of the practice.

Identify and Include Relevant Keywords

When you apply for a job as a medical records coordinator, your resume is likely to be scanned by an applicant tracking system (ATS) for certain keywords. This software looks for certain terms related to the job, like “medical records” and “healthcare” in order to determine whether your skills and experience are a match for the position. If you don’t have the right keywords on your resume, it might not make it past the ATS and into the hands of a recruiter.

To make sure you include all the right keywords on your medical records coordinator resume, refer to the list below:

• Medical Records
• Electronic Medical Record (EMR)
• U.S. Health Insurance Portability and Accountability Act (HIPAA)
• Medical Terminology
• Healthcare Management
• Healthcare Information Technology (HIT)
• Healthcare Information Management
• Medical Billing
• Medical Coding
• Cardiopulmonary Resuscitation (CPR)
• Administrative Assistance
• Medical Transcription
• Office Administration
• Insurance Verification
• Customer Service
• Patient Safety
• Hospitality
• Hospitality Management
• Time Management
• Hotel Management
• Public Speaking
• Food & Beverage
• Microsoft Access

Showcase Your Technical Skills

As a medical records coordinator, you will be responsible for maintaining and organizing patient medical records. To do this effectively, you will need to be proficient in the use of various software programs, such as electronic health records (EHR) systems, medical coding systems, and medical billing systems. You should also be familiar with Microsoft Office Suite programs, such as Word and Excel, as you will need to use these to create reports and track data.

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Medical Records Technician Resume Samples

The guide to resume tailoring.

Guide the recruiter to the conclusion that you are the best candidate for the medical records technician job. It’s actually very simple. Tailor your resume by picking relevant responsibilities from the examples below and then add your accomplishments. This way, you can position yourself in the best way to get hired.

Craft your perfect resume by picking job responsibilities written by professional recruiters

Pick from the thousands of curated job responsibilities used by the leading companies, tailor your resume & cover letter with wording that best fits for each job you apply.

Create a Resume in Minutes with Professional Resume Templates

• Assists in preparing and filing all internal and external correspondence and medical reports into patients medical record according to filing system
• Prioritizes daily work to include independent problem solving and decision making without daily supervision
• Pulls charts for telephone messages and delivers to physicians, phone nurse and medical assistants. Sends outgoing faxes and distributes incoming faxes
• Properly sends medical records to the correct mailing address or fax number as stated on medical record copying request. Process medical records on CD
• Correctly identify patient on medical record copying request by searching for correct medical record number in Company EMR system
• Supports all functions within the cancer registry to include case finding, follow-up and staging
• Opens and closes case files; indexes and files medical records and reports; maintains tickler file and patient registry for tracking and reporting purposes
• Documents work completed
• All other duties assigned by Management
• Downloads medical records from a VA system
• Maintains and protects the confidentiality of medical record
• Proficient in general computer use and Microsoft Office Suite
• Uses software to capture and/or merge data/information with a wide variety of word processing, graphics, and desktop publishing software packages
• Converts medical records to PDFs
• Provides guidance and technical direction necessary for accomplishing the work of the unit or team, including providing support at the ROI Reception Window
• Serves as work leader, assuring the work assignments of employees in the unit are carried out
• Maintains records of work accomplishments
• Facilitates team or unit processes by working in collaboration with team members or employees to ensure that tasks are completed
• Interacts with team members aimed at building consensus and to serve as negotiator and coach for coordination of team initiatives
• Serves as a subject matter expert (SME) to team members and internal and external customers
• Trains team members in the accomplishment of tasks or projects, including the burning of medical record and/or radiology CD's
• Necessary skills include the ability to type 50 WPM, computer skills, knowledge of general office duties and excellent communication
• Knowledge of Health Care System Knowledge of medical terminology
• Ability to compile data and prepare detailed reports and charts
• Ability to communicate clearly and professionally
• Excellent attention to detail
• Ability to research and solve coding and documentation related issues; and
• Knowledge of medical terminology
• Ability to review, update and manage data in an electronic disease database
• Knowledge of Microsoft Excel and Microsoft Word
• Ability to convey information to customers in a warm, clear, concise manner

8 Medical Records Technician resume templates

Read our complete resume writing guides

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• Reviews and evaluates electronic medical reports for completeness and conformity with standards; resolves deficiencies in information
• Receives and processes electronic data files from cancer reporting facilities
• Reviews diagnoses of diseases, operations, illnesses and special therapies in accordance with the specific nomenclative and classification system
• Coordinates a variety of activities with public and private health care facilities such as the receipt and transfer of paper and electronic cancer case reports
• Prepares medical records for storage in archives
• Compiles data and prepares a variety of medical and statistical reports
• Makes recommendations for workflow enhancement related to programplanning and cost efficiencies
• Six months experience in document processing which includes reviewing and evaluating records for completeness and conformity with laws, rules, regulations, standards, policies and procedures, resolve deficiencies, interpret information, and track and monitor activities
• Six months experience in record keeping
• Knowledge of principles and practices of maintaining medical records including standard nomenclature and classification systems and program procedures
• Knowledge of applicable legal and administrative requirements pertaining to the confidentiality and release of information, retention and disposal of medical records
• Knowledge of office equipment
• Ability to apply the international classification of diseases to medical records and report data
• Ability to interpret, code, file and index paper and electronic medical records and reports

Msla-medical Records Technician Resume Examples & Samples

• Utilize a PDF program and high-speed production scanners for the purpose of transforming hard copy documents into an electronic format
• Appropriately note the steps taken during file conversion within our system, and ensure accuracy by recording information pertinent to the scanned file in question
• Basic knowledge of Microsoft Word and Excel
• Minimum 1 year of experience working in Medical Records and with diagnostic reports and document imaging technology software
• AA / AS degree, M.A. Certification or equivalent
• Obtains and distributes medical records to clinical staff for the provision of patient care. The MRT highlights gaps in care results for abstraction by clinical staff into the medical record. This position will be able to perform data abstraction within scope of the MRT
• Answers telephone related to medical records requests and is able to take messages for other phone calls as needed
• Reviews requests for records release, provides records per policy, and documents release of information appropriately in the EHR. The MRT communicates with Custodian of Records for records requests by attorneys, patients, and insurance companies as needed
• Ensures compliance with state statutes and internal policies and procedures prior to processing requests
• Appropriately logs and routes incoming records to PHM clinical staff for review and inclusion into the EHR
• Demonstrates a positive customer service approach in all internal and external customer experiences following all Courtesy Behaviors
• One year experience in health care, with experience in medical records preferred

Msla Medical Records Technician Sorters Level Resume Examples & Samples

• Convert hard copy documents into an electronic PDF format which uploads into a centralized database
• Identify listed medical or psychological conditions, including all related conditions or triggers, and electronically index each according to their medical specialty
• Basic knowledge of Microsoft Word and Excel required
• Minimum 1 year of experience working in Medical Records and with diagnostic reports and document imaging technology software preferred
• AA/AS degree, M.A. Certification or equivalent preferred
• Licensed Vocational Nurse (LVN), Pharm Tech, Paramedic, Radiology Technician preferred
• Collect clinical information and enter the data into abstraction software
• Consistently meet or exceed productivity and accuracy standards
• Experience reading inpatient hospital medical records
• Ability to work well in a team environment
• Must be proficient in Microsoft Office Suite
• Ability to read fast while gathering specific data
• 02-03 years w/High School Diploma
• Experience analyzing, interpreting, and applying regulatory requirements in regards to medical records maintenance
• Experience entering, accessing, and retrieving patient information in Composite Health Care System (CHCS) or similar automated systems in order to perform records analysis and tracking
• Experience providing general office services such as responding to information requests and document management
• KNOWLEDGE OF MEDICAL RECORDS MAINTENANCE PROCESS
• SKILL IN MEDICAL OFFICE ADMINISTRATION PROCEDURES
• ABILITY TO PERFORM CUSTOMER SERVICE IN A MEDICAL ENVIRONMENT

Supervisory Medical Records Technician Inpatient Technical Section Resume Examples & Samples

• Travel may be required for training and/or meetings
• A one-year supervisory/managerial probationary period may be required upon selection/placement
• This position is not covered by a Bargaining Unit
• This position has no promotion potential
• No government housing authorized
• Follow the prompts to complete the assessment questionnaire and upload required documents
• Click to view and print the assessment questionnaire View Occupational Questionnaire
• Current or former Federal employee: Include your most recent SF50, Notification of Personnel Action, or if Reinstatement eligible include your Career SF-50
• Noncompetitive eligibles – submit additional documents to prove your eligibility to apply to this vacancy
• Childcare Addendum form must be included for this position and is available for downloading at: https://www.ihs.gov/jobs/index.cfm?module=support
• Reviews requests for release of information and processes requests made by patients, attorneys, insurance companies and other health care clinicians. Ensures compliance with state statutes and internal policies and procedures prior to processing requests
• Appropriately logs and routes incoming records to providers for review and inclusion into the EHR
• Demonstrates a positive customer service approach in all internal and external customer experiences

Supervisory Medical Records Technician Resume Examples & Samples

• 5 % Travel for Training
• Knowledge of Supervisory Personnel Functions
• Knowledge of Quality Assurance
• Skill in Work Management
• Ability to Communicate with Managers

Medical Records Technician Vista Scanner Be Be Resume Examples & Samples

• Control Number
• Print this 1203FX form to provide your response to the assessment questionnaire http://www.opm.gov./Forms/pdf_fill/OPM1203fx.pdf
• Fax the completed 1203FX form along with any supporting documents to 1-478-757-3144. Your 1203FX will serve as a cover page for your fax transmission
• Resume - You are highly encouraged to use USAJOBS Resume Builder to ensure all required information is included in your Resume. If you use your own resume, curriculum vitae, or any other written form you choose then you must describe your job-related qualifications that includes beginning and ending dates for paid and non-paid work experience, hours worked per week, month and year of employment for each job title listed, annual salary, and description of job duties. Include name and address of employer; supervisor name and telephone number
• Veteran's Preference – If claiming Veteran's Preference provide a copy of your DD214 Form (Member 4 copy). To claim 10-Point Veteran's Preference, submit a SF-15 Application (http://www.opm.gov/forms/pdf_fill/SF15.pdf) along with the appropriate supporting documentation. For additional information regarding Veteran's Preference visit: www.fedshirevets.gov

Medical Records Technician Oa Resume Examples & Samples

• Ability to Analyze Medical Record Data
• Knowledge of Data Retrieval
• To return to an incomplete application, log into your USAJOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USAJOBS account or your application will be incomplete
• Qualified. Candidates in this category meet the minimum experience requirements for the announced position

Msla-medical Records Technician Downloader Resume Examples & Samples

• Minimum 1 year of experience working with document imaging technology software
• Minimum 1 year of experience working in Medical Records
• Uses software to capture and / or merge data / information with a wide variety of word processing, graphics, and desktop publishing software packages
• 1+ year of experience working with document imaging technology software
• 1+ year of experience working in Medical Records
• Ability to coordinate work in order to complete duties in an accurate and timely fashion
• Ability to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record
• Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines
• Knowledge of severity of illness and risk mortality indicators

Supervisor Medical Records Technician Resume Examples & Samples

• Proving effective audits and monitoring for all areas of responsibility
• Reviewing work accomplished and assessing quality, quantity, accuracy and timeliness of work produced by employees
• Ascertaining problems encountered and taking corrective action
• Developing performance standards and conducting performance evaluation
• Preparing and submitting functional statements for new positions, clarification or updates
• Ensuring release of information activities related to the development, implementation, maintenance if adherence to privacy policies and procedures are performed and coordinated in compliance with applicable federal laws and regulations
• Ensuring record retrieval and record transfers are timely; and
• Monitoring workload and production of staff
• Ability to develop policy and provide workload analysis for ROI
• Leadership and managerial skills, including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers
• Ability to provide or coordinate staff development and training; and
• Knowledge of, and ability to provide, the full range of supervisory duties to include responsibility for assignment of work to be performed, performance evaluation, selection of staff, and recommendations of awards, advancements, and, when appropriate, disciplinary actions
• Basic knowledge of disease processes and human anatomy
• Basic knowledge of medical record/health information guidelines, techniques, and procedures
• Knowledge of the medical and legal significance of medical records
• Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines
• Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA))

Medical Records Technician External Resume Examples & Samples

• Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.)
• ) Ability to navigate through health records to find needed information
• )Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines
• ) Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and accountability Act (HIPAA)); and
• ) Comprehensive knowledge of classification systems, such as current versions of International Classification of Disease (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation
• ) Skill in applying current coding classifications to variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record
• ) Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or procedures, and the relationship between health care documentation and code assignment
• ) Ability to research and solve coding and documentation related issues; and
• ) Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete
• ) Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient
• ) Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/ or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and
• ) Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines
• Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with medical record documentation educational, and functional training requirements to ensure program objectives are met for CVAMC clinical and medical record staff
• Ensures active intra-departmental training program is in place for the medical records staff. Determines and meets training needs of extra-departmental professional, para-professional and non-professional personnel by origination training material, providing orientation to newly assigned interns and residents, participating in in-service programs conducted throughout the hospital
• Facilitates improved overall quality, completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIMS coding staff to ensure clinical documentation and services rendered to patients is complete and accurate
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis
• Collaboratively works with the professional clinical staff and provides support and education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to insure that all information is fully documented and supported. Such efforts are conducted to insure the accuracy and quality of healthcare given, billing denials, prevention against fraud and abuse to maximize the medical center's authorized reimbursement for utilization of resources provided
• Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities, including SAIL data. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay
• Ability to establish and maintain strong verbal and written communication with providers
• Knowledge of severity of illness and risk of mortality indicators; and
• Certification is highly desirable for these vacancies and it must be from the American Academy of Professional Coders (AAPC) as a certified Professional Coder
• Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or
• Skill in applying current coding classifications to a variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record
• Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment
• Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient
• Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines

Medical Records Technician Coordinator Resume Examples & Samples

• Coordinates with representatives of other units to solve related Cancer Registry functions
• Extensive knowledge and understanding of ACoS and/or facility requirements for administering, monitoring and reporting compliance of the cancer program to the governing bodies
• Ability to interpret data in order to set, evaluate and adjust cancer program and/or facility goals and objectives
• Ability to inform cancer registry staff on the technical components of the cancer database, coordinate work flow and monitor data for accuracy and quality measures
• Ability to communicate with diverse disciplines regarding the facility requirements of the cancer program
• Ability to analyze and interpret data for use in facility strategic planning
• Ability to develop cancer program/cancer registry policies and procedures to ensure patient-center care for cancer patients in accordance with government-wide, agency, and facility requirements
• Knowledge of the applicable regulatory guidelines and requirements for current coding conventions
• Knowledge of coding classification systems
• Ability to format and present results and provide guidance to improve accuracy
• Providing oversight of a group of Medical Record Technicians, with administrative responsibility for planning and directing the work of subordinate staff
• Evaluating the performance of subordinate staff, approving sick and annual leave requests, identifying educational or training needs, resolving employee complaints and taking disciplinary actions, when necessary
• Informing higher level management of anticipated vacancies or increases in workload
• Selecting and assigning codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding Systems (HCPCS)
• Applying codes based on guidelines specific to certain diagnostics, procedures and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program
• Monitoring ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided
• Performing comprehensive review of patient health record to abstract medical, surgical, ancillary, demographic, social and administrative data to ensure complete data capture
• Utilizing a variety of window based applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access, as well as electronic health record applications (VistA and CPRS) as well as the encoder product Suite
• Leadership and managerial skills including skill in interpersonal relations and conflict resolution to deal with employees, team leaders and managers
• Assigning codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the Medical Center
• Assigning codes from the current version of several coding systems to include current versions of the International Classification of Disease (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS)
• Adhering to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding
• Applying codes based on guidelines specific to certain diagnosis, procedures, and other criteria (inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program
• Monitoring changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the Medical Center
• Performing a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture
• Assisting facility staff with documentation requirements to completely and accurately reflect the patient care provided
• Using a variety of windows based applications such as Outlook, Excel, Word, and Access
• Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record
• Ability to correctly apply a practical knowledge of laws and regulations related to the confidentiality of health information and the release of information from medical records
• Knowledge of the internal organization of medical records and medical record references and procedures as appropriate to the position
• Ability to use health information software appropriate to the position, such as the electronic patient record, record tracking systems, chart deficiency systems, coding and abstracting systems, release of information systems, document scanning technology, electronic spreadsheets, transcription systems, encoder products, electronic encounter forms, database software, etc
• Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes to fully understand the content of a patient record
• Ability to navigate efficiently through the paper and electronic medical record to find needed information
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity and ability to use judgment in completing assignments with incomplete or inadequate guidelines
• If assigned to medical record analysis, ability to judge whether medical records contain sufficient information for regulatory requirements; are acceptable as legal documents; are adequate for continuity of patient care; and support education and research needs. This includes the ability to take appropriate actions if medical record contents are not adequate; accurate, timely, and/or reliable
• Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA)
• If assigned to a tumor registry position, ability to apply guidelines and standards for the maintenance of an approved tumor registry; and
• If assigned to a medical coding position, comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT), the Systematized Nomenclature of Medicine (SNOMED) or Healthcare Common Procedure Coding System (HCPCS), and skill in applying coding knowledge
• Tumor Registry Positions.Tumor registry assignments at this level represent the advanced developmental level leading to the full performance level. At this level, MRTs in tumor registry assignments perform a substantially full range of duties but will receive more guidance and direction regarding unfamiliar or unusual situations
• Tumor Registry Positions.This is considered to be the full performance level for tumor registry assignments. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs

Medical Records Technician Auditor Resume Examples & Samples

• Perform prospective coding audits and utilize results to identify processing inadequacies and re-educate coding staff where necessary
• Plan, organize, direct and control areas with emphasis on data validation, analysis
• Generate reports associated with the Medical Center's health information management program
• Review, analyze and report performance monitors for PTF, PCE, VERA and Non-VA Medical Care (purchased care) coding
• Collaboratively works with coding staff and clinical staff and provides support and education on coding issues
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management
• Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions, and documentation requirements; and
• Prepares charts for patient visits which includes requesting copies of records from various providers via phone, fax and mail and ensuring all documentation is in the file
• Copies, mails, and/or faxes patient chart information as requested and authorized
• Pulls and delivers charts as requested by physicians, nurses and medical assistants
• Minimum three years office experience, preferably in a medical setting
• Prior experience in medical records strongly preferred

Lead Medical Records Technician Resume Examples & Samples

• Communicates to the team the problem to be solved or program issues under review, and coaches the team and/or individual team members in identifying the parameters of a viable solution
• Trains team members in the accomplishment of tasks or projects, including the burning of medical record and/or radiology CD's
• Ability to communicate tactfully and effectively, both orally and in writing, in order to meet program objectives. This may include preparing reports in various formats and presenting data to various organizational levels; and
• Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work
• Applying current coding classifications to a variety of specialty care areas which accurately reflect service and care provided based on documentation in the health record
• Communicating with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment
• Researching and solving coding and documentation related issues
• Reviewing and correcting system or processing errors and ensuring all assigned work is complete
• Identifies required reportable diseases in this facility's patients through the use of the VISTA Oncology Program and Laboratory Package
• Thoroughly searches the medical record to identify and code all information pertinent to the patient's diagnosis
• Utilizes coding references to ensure that complete and accurate data is collected
• Codes stages of disease using American Joint Commission on Cancer's staging requirements
• Analyzes the consistency of coding registry data, cancer diagnosis, and histology, treatment, (including surgical procedures, chemotherapy, immunotherapy, hormonal therapy and radiation therapy)
• Identifies coding discrepancies
• Facilitates resolution of coding discrepancies by discussion with providers and registrars
• Codes complicated medical records having diagnostic, surgical and therapeutic procedures that are identified as difficult to classify
• Reviews records to obtain data
• Enters data obtained from record into the registry software
• Analyzes data retrieved and provides the results to health care staff for research, patient care, budgeting, protocol studies and trends in cancer
• Advanced knowledge of medical terminology, staging of cancer, and requirements of internal and external approving organization
• Knowledge of cancer committee processes and procedures in order to improve patient care and verify compliance with ACoS and/or facility standards
• Ability to serve as a subject-matter-expert on cancer programs for the medical center; and
• Skill in utilizing electronic health records and cancer registry software
• GRADE DETERMINATIONS
• PREFERRED EXPERIENCE

Medical Records Technician, GS Resume Examples & Samples

• Abstractions and processes medical releases' of information requests
• Follows rules of Privacy Act, the Freedom of Information Act, VA regulations, and the Health Insurance Portability and Accountability Act (HIPAA)
• Reviews and analyzes written and telephone requests to ascertain type of request to be processed
• Develops and prepares case files
• Receives and enters data into tracking systems
• Generates reports
• Communicates with medical staff to resolve problems
• Advises and assist Veterans in preparation of record requests
• Process Automated Medical Information Exchange (A.M.I.E.) requests for records, and compiles records for release
• Utilizes various automated systems to process and track requests for information
• Computes appropriate copying fees/generates accurate billing
• Assists in the training of new employees

Medical Records Technician GS Resume Examples & Samples

• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines
• Comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation
• Skill in interpreting and adapting health information guidelines
• Ability to Supervise
• Knowledge of Outpatient Medical Records
• Skill in Oral and Written Communication

Medical Records Technician File Scanner Resume Examples & Samples

• Occasional travel may be required for training and/or other work related duties
• Schedule A Appointments for the Disabled
• Locates missing charts as needed. Assists in preparing and filing all internal and external correspondence and medical reports into patients medical record according to filing system
• Picks up outguides at designated locations and returns to Medical Records
• Replaces damaged charts as needed, and/or starts a second volume when chart space has been maximized
• Keeps a record of new patients for weekly physicians meeting and pulls appropriate charts. Provides back-up assistance as needed by front office staff
• Minimum of three years office experience, preferably in a medical office setting
• Previous experience in a medical records department
• Knowledge of standardized body of rules, procedures, and operations
• Knowledge of regulatory/legal requirements of Medical Records administration
• It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date
• Perform quantitative/qualitative analyses of records to ensure components of the records are present, accurate, and comply with VA and Joint Commission (JC) requirements
• Ensure documentation is present in appropriate format and sequence, identified and signed to meet JC and VA requirements
• Records are reviewed thoroughly for documentation of final diagnosis and procedures, complications and co-morbid conditions, signatures and overall adequacy
• Ensure physician documentation supports the diagnoses and procedures coded
• Completes Patient Treatment File (PTF) entries by abstracting information, including clinical and demographic information, from the record
• Ensures all Contracting Nursing Home (CNH) patient information is properly coded, input, and released
• Codes diagnoses, operations and procedures (inpatient and outpatient), which requires the incumbent to be knowledgeable in a variety of coding systems, using ICD-9-CM, CPT, and HCPCS ensuring completeness and conformance to accepted VA regulations, JC requirements, ICD-9-CM coding conventions and guidelines for optimal Diagnostic Related Group (DRG) assignment
• Codes information from the medical records of patients to generate a clinical patient care database for the facility
• Reviews and screens the entire medical record to abstract medical, surgical, laboratory, pharmaceutical, demographic, social and administrative data from the medical record in a timely manner; and
• Participates in regular meetings with the objective of solving problems, brainstorming, educating physicians and others as to the coding policies and procedures of the facility, as well as promoting consistency of data collected
• Screens each request for information to determine urgency and assures that most urgent requests are completed first using established priority systems
• Performs front desk and customer service functions including answering phones, returning voicemail messages and distributing mail. Greets Veterans /visitors, and assists them in determining the exact nature of their request and whether the information requested can be released
• Abstracts and processes medical release of information requests that pertain to the Privacy Act, the Freedom of Information Act (FOIA), and Health Insurance Portability and Accountability Act (HIPAA); requests for information from patient's medical records for release to appropriate facility, agency or physician
• Screens and follows through on all incoming telephone calls from attorneys and insurance representatives, regarding legal cases and requests under the Privacy Act, referring only problem cases to the Supervisor
• Reviews information to be released for completeness, signatures, etc., by reading material and checking request for release of information, ensuring that information being released is limited to material requested and conforms to VA directives and policies
• Completes and processes routine releases of information to other VA and Federal Agencies and, when requested, to patients and their families, insurance representatives, physicians, hospitals, and city and state health agencies according to VA directives. Processing must be accomplished within established time standards
• Accurately enters all requests into the Document Storage System Release of Information (DSS ROI) software with necessary information for each request for medical information. Responds timely and accurately to subpoena, individual, copy service, and legal organization requests
• Processes Social Security requests for medical information using DSS ROI software. Downloads VistA Imaging documents and DSS ROI documents into a secured Drive. Accesses the secured Social Security Web page and uploads the documents to the Web site
• Obtains a special consent from the patient to release medical information of a sensitive nature i.e. HIV testing/information, alcohol and or drug abuse or sickle cell anemia information to a third party
• Releases information in medically emergent situations to private health care facilities and private physicians
• At the discretion of the supervisor, the incumbent may be assigned to different work areas (e.g. Oakland OPC) to provide coverage via travel be government vehicle or private vehicle with travel reimbursement
• To other NCHCS sites
• Ability to utilize health information technology and various office software products utilized in MRT (ROI) positions (e.g., the electronic health record, release of information systems, etc.)
• Ability to research and solve difficult questions related to release of information in an accurate and timely manner
• Case Finding
• Abstracts, Codes and Maintains Registry Records
• Quality Control - Develops and monitors quality management and improvement, performance projects and special studies to enhance cancer patient care to meet requirements of the commission on cancer
• Cancer Committee
• Tumor registry administrative management
• Ability to analyze the electronic health record and enter appropriate data into the OncoTrax cancer registry software abstract; and
• Knowledge of ACoS standards regarding tumor board, including clinical staging, prognostic indicators, clinical guidelines, and clinical trials availability
• Advanced knowledge of medical terminology, staging of cancer, and requirements of internal and external approving organizations
• Ability to serve as a subject-matter expert on cancer programs for the medical center; and

Medical Records Technician Documentation Improvement Specialist Resume Examples & Samples

• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection
• Serves as technical expert in health record content and documentation requirements
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS)
• Searches patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the FHCC
• Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff
• Complies, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities
• Assist all clinical providers with ICD, CPT, and DRG methodologies so that documentation will accurately reflect the occurrence of the encounter; and
• Maintains statistical database(s) to track the results and validate the program for identifying
• Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators
• Acts independently to plan, organize, direct and control area with emphasis on data validation, analysis and generation of reports
• Assures data entered into databases are complete, accurate and consistent with the documentation in the health record
• Assures CPT and ICD codes, DRG and modifiers can support clinical and physician medical documentation for proper and consistent data collection and reimbursement
• Ensures physician documentation supports the diagnoses and procedures coded
• Extracts information, generate reports from various databases and analyze data
• Provides direct data entry into major data bases from which the facility funding is derived: the Patient Treatment File (PTF) data for inpatient and Patient Care Encounter (PCE) data for outpatient
• Furnishes guidelines and advice to the Health Information Management Section and the medical staff
• Determines quality control measures needed; initiates and implements them by use of monitors, systematic review, clinical pertinence reviews, and other applicable methods; and
• Provides support and education on documentation and issues to assist in the development of guidelines for data compatibility, consistency and monitoring of compliance
• Analyzes and abstracts inpatient and outpatient surgery records. Provides database for medical administrative planning and health care programs
• Analyzes inpatient and outpatient surgery records for documentation deficiencies. Follows medical staff by-laws, reimbursement requirements and Joint Commission on Accreditation of Healthcare Organization standards relative to completion of medical records. Identifies deficiencies and discrepancies
• Re-analyzes chart upon completion of deficiencies by medical, nursing and ancillary staff
• Performs medical record review activities. Ensures timely completion of medical record by responsible practitioners. Summarizes and reports results of review activities to hospital administration and medical staff
• Adheres to and maintains current knowledge of Principles of Responsibility, applicable federal and state laws and regulations, accreditation and licensing requirements, policies and procedures. Reports and/or resolves issues of non-compliance
• On regular, sustained basis, cooperates with other staff members both within and outside department in accomplishment of own job duties as well as assisting others in accomplishing theirs. Serves as team player and role model for other employees in organization, always exhibiting traits of courtesy, caring, helpfulness and respect. Conducts self in service-oriented manner that is attentive, pleasant, cooperative, sensitive, respectful and kind when dealing with members, visitors, public and all employees
• Post high school coursework in medical terminology, medical records; or equivalent related experience
• Minimum one (1) year of medical records experience
• 2 semesters of Anatomy and Physiology with grade of C or better
• Successful completion of an Associate's degree or equivalent 60 college-level credits
• 5 As Needed. Performs various duties as needed to successfully fulfill the function of the position
• Must have above average proficiency on Outlook, Excel, Adobe, and Word
• Excellent customer service skills and must be able to be sensitive and respectful of our patient's needs
• Must be able to follow rules and policies about patient privacy (HIPAA)
• Must be able to electronically scan medical records and maintain any file storage
• Must be able to work successfully with a diverse group of faculty, other staff, and members of the public
• Pulls charts, files outguides, and delivers requested charts to designated locations
• Makes copies of dictated interval notes accordingly
• Assists in purging deceased and inactive charts as scheduled and according to guidelines
• Pulls charts, dates and stamps and attaches encounter form
• Drops encounter form when there is a cancellation
• Pulls charts for telephone messages and delivers to physicians, phone nurse and medical assistants
• Sends outgoing faxes and distributes incoming faxes
• Keeps a record of new patients for weekly physicians meeting and pulls appropriate charts
• Keeps inventory and orders office supplies as needed
• Runs office errands as needed
• Minimum of one (1) year office experience, preferably in a medical office setting
• Image, imaging experience required
• Account for and file Emergency Department reports
• Account for the return of medical records from authorized users and verifies correct chart order before re-filing
• Communicate clearly with front desk, phone team and Worker's Comp dept.in the Epic/EpicCare system
• Demonstrate a service oriented approach to his/her position by conveying courtesy, respect, enthusiasm, and a positive attitude in work situations by showing initiative and offering assistance to other staff members and hospital personnel in the completion of the department's work, and by making patient care and/or interdepartmental service the first priority while working
• Electronically index patient medical information efficiently, keep outstanding batches to a minimum
• File loose medical reports, x-rays, correspondence, etc., appropriately within the medical record
• File medical records into permanent, secondary, and off-site storage locations as indicated
• Maintain the neatness and accuracy of permanent, secondary, and off-site storage locations
• Maintain weekly counts of records retrieved for patient care, billing and research
• Obtain approval to remove medical records from the legal file and insure their correct return
• Prepare new record folders / contents as necessary
• Process all requests for photocopies of medical records, as received from patients, the Billing Office, and physicians or their secretaries. Ensure that a proper written patient authorization is received for each request and is filed with the medical record
• Retrieve medical records from permanent and off-site storage locations for physicians, the Billing Office, and all other authorized department personnel
• Routinely monitor incoming faxes, dispersing documents to correct departments or persons
• Take calls in timely manner from telephone team and gather all Worker's Comp and Auto insurance information from patients
• Verify Worker's Comp & Auto insurance claims
• High school graduate or equivalent is required
• Must be adept with the alphabet and numerals
• Must demonstrate good organizational and communication skills
• Typing skill is preferred but not mandatory
• Must have the ability to ambulate and to perform some lifting functions

Medical Records Technician / Receptionist Resume Examples & Samples

• Two (2) years of EHR or healthcare information system experience in a psychiatric inpatient or outpatient program or acute hospital setting and Completion of an approved Health Information/Medical Record Program experience in the management of behavioral health clinical records
• EHR System experience, Caminar, Avatar (desired)
• Knowledge and application of appropriate coding systems; ICD-10 CM, DSM IV
• Knowledge of documentation and legal issues pertaining to HIPAA, PHI and other health information
• A high school diploma or a G.E.D
• The ability to work with minimum of supervision, set work priorities and function as a self-starter is essential
• Must have the willingness to work with individuals with mental illness
• One (1) year of EHR or healthcare information system experience in a psychiatric inpatient or outpatient program or acute hospital setting
• Working knowledge of managing a hybrid medical record system
• Knowledge of local, state and federal regulations, survey process, accreditation standards, and psychiatric requirements
• Proficiency in Microsoft Office 365
• Sensitivity to multi-cultural populations and issues
• Ability to communicate effectively with staff and County representatives
• Ability to read, write and speak English is crucial, as is the willingness to work with mentally impaired adults
• Must be CPR, ProAct or CPI and First Aid certified on date of employment or within 60 days of employment and maintain current certification throughout employment
• All opportunities at Telecare are contingent upon successful completion and receipt of acceptable results of the applicable post-offer physical examination, 2-step PPD test for tuberculosis, acceptable criminal background clearances, excluded party sanctions, and degree or license verification. If the position requires driving, valid driver license, a motor vehicle clearance and proof of auto insurance is required at time of employment and must be maintained throughout employment. Additional regulatory, contractual or local requirements may apply
• Assists in the development of and compliance with the policies and procedures that ensure that medical records are complete and processed according to governmental regulations and standard professional and medical record keeping practices
• Monitors and tracks compliance with legal documents and correspondence with conservators/guardians
• Prepares and processes the clinical records of clients who are admitted/discharged in the program
• Audits clinical records for completeness and adherence to standards
• Ensures that data is collected accurately and on time
• Ensures that clinical staff understands the significance of inputting key data elements
• Verifies accuracy of data
• Ensures that client information, admissions, discharges, eligibility information, outcome data and other pertinent information is documented within specified time limits
• Interfaces with County staff and confirms that all system data procedures are completed according to County specifications and directions
• Creates and runs reports to confirm accuracy of data and makes corrections according to County instructions within specified timelines
• Participates in all system trainings and meetings to stay up-to-date on all changes and revisions to system
• Performs computer interface (uploads) of data to Corporate office
• Duties and responsibilities may be added, deleted and/or changed at the discretion of management
• This role will oversee two Programs
• Credentialed as a Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA), through AHIMA*
• Experience working with individuals with a Mental Health diagnosis is highly preferred
• If the position requires driving, a motor vehicle clearance and proof of auto insurance is required prior to hire. Additional regulatory, contractual or local requirements may apply
• Provide each patient with an exceptional customer experience by greeting them with a warm welcome and smile as you interact with them. Maintain eye contact
• Communicate with patients promptly and efficiently using words the patient understands; keep the patient informed of delays in service and/or clinician wait times
• Anticipate patient’s stated and unstated needs. Talk with them in depth so you understand what the patient truly needs. Provides explanations and support to meet those needs
• Consistently keep personal conversations private and out of the work environment
• Patient information is consistently maintained in a private and secure manner, complying with HIPAA Guidelines at all times
• Consistently thanks the patient for allowing Cigna Medical Group to provide their healthcare and ask if there is anything else we can do for them during their visit
• Analyzes medical records in order to ensure completeness and records data received
• Completes daily, monthly, and annual statistics
• Checks and codes completed medical records
• Abstracts information from medical records of discharged patients
• Gathers medical records of incoming patients for physician's use
• Assembles medical records of discharged patients
• Releases health information according to policy
• Collects and files a variety of medical records into an electronic records system. Reviews files for accuracy, orderliness, proper categorization, and visual quality. Takes remedial action when necessary
• Researches, collects, and retrieves records to respond to internal and external requests. Ensures requested information is disseminated in accordance with HIPAA, HITECH, PHI, and GRAMA policies, statutes, and laws
• Schedules a variety of medical appointments and prioritizes based on medical need. Coordinates appointments with medical and program staff. Ensures medical records are available when needed
• Creates and maintains logs containing medical services provided
• Reviews medical charts for possible classification into available jail programs; safeguards jail records and verifies payment of required fees
• Prepares charts and paperwork, answers telephones, receives and distributes correspondence, and assists in other areas when needed
• Prefer at least 1 year experience in a medical record office setting
• Prefer experience with terminal digit filing system
• Prefer knowledge of medical terminology
• PHYSICAL REQUIREMENTS
• Knowledge of and well established medical record procedures and regulations to include administration, filing, researching, handling, securing and completing sufficient to provide properly filed and completed patient records
• Knowledge of medical terminology; the structure and physiology of major anatomical systems and the major diseases of each to code and maintain medical records
• Knowledge of general office administrative and clerical procedures to perform receptionist duties, answer telephone, distribute mail, maintain office files/forms, and order supplies; and correct grammar, spelling, punctuation, capitalization, and format to accurately prepare and edit written documents and reports. Knowledge of basic office automation software to perform functions such as standardized word processing and receipt or transmission of electronic mail
• Skill in gathering required data and preparing related reports
• Ability to analyze medical records, apply appropriate codes, and determine medical and legal sufficiency of the record
• Skill in typing; a qualified typist is required
• Knowledge of Medical Records Content, References, Policies, and Procedures
• Skill in Performing Customer Service
• Skill in Operating Automated Computer Systems, Software Programs, and Standard Office Equipment
• Ability to Manage Medical Records
• Ability to Manage Extended Ambulatory Medical Records, Labels, Documents, and Files
• Checks new admits and corrections; deletes duplicate orders
• Forwards all medication orders to Order Entry Technicians for entry
• Receives physician order sheets and telephone orders and file monthly for future archive storage
• Works with directors of nursing on resident set-up
• Assists with conversions and new home start-ups along with pharmacy data entry as required
• Reviews and edits monthly physicians order forms and telephone orders returned to the pharmacy, to input recap notations, non-medication order changes and other information provided relative to medical records
• Reviews each centers requirements for medical records with the center supervisor, pharmacy consulting staff, account management, DON, etc. to set up center specific medical records
• Manage discharges, room changes and doctor changes on profile
• Accurate maintenance of all facility forms and reporting information
• Print monthly medical records package which includes physician orders, medication sheets, treatment sheets, flow records, etc. for all facilities
• Follow all applicable government regulations including HIPAA
• Courteously assist internal and external customers
• Other duties as assigned; Job duties may vary by location

Related Job Titles

Medical Records Clerk Resume Sample

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Work Experience

• Uses, protects, and discloses DaVita Medical Group patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Create and maintain medical records, general files, logs and other related records and documents in an organized manner, to include sorting, labeling, filing and retrieving, in accordance with corporate and facility file retention and storage procedures; and maintains confidentiality and security of records
• Assist in the preparation of routine medical and dental reports
• Read and comprehend medical instructions and procedures, correspondence, policies, regulations, reports, directions for forms completion and other simple or moderately complex document or moderately complex documents
• Processing AB610’s and insurance requests for copy services
• Working knowledge of basic medical office practices and procedures
• Responsible for the accurate and timely filing of all patient medical records according to Company procedures
• Assures medical records are pulled immediately for all patient triages and provided to clinicians in a timely manner
• Pulls all medical records for non-urgent phone messages, reports, etc
• Communicates necessary information to Supervisor and management staff to assure accuracy of data
• Performs administrative and office support activities
• Answers and transfers incoming telephone calls
• Performs word processing, filing, and email/faxing
• Extensive software skills & competencies are required, as well as Internet research abilities and strong communication skills. Includes: MS Office (Outlook, Word, Excel, PowerPoint) and also preferably a familiarity with Visio, Project and Access)
• Work under the direction of the Office Manager/ Head of the Records Department
• Order medical records using our Needles database in conjunction with ARC
• Follow up on medical records, communicate with clients regarding treatment facilities as well as communicate with facilities and providers regarding records
• Reviews schedule and pulls patient charts for all office visits in a timely and accurate manner
• Reviews records to ensure required reports and signatures are included
• Purges charts on a timely basis and follows process for storage according to Company policy
• Copies and maintains medical records logs for all urgent copy requests
• Prepares and monitors all outside copy services
• Maintains strict confidentiality of all information within the facility
• Completes daily tasks to maintain medical record compliance

Professional Skills

• PC skills- demonstrate proficiency in Microsoft Office applications and others as required
• Keyboarding skills at 25-30 w.p.m
• Moderate typing skills, data entry, filing and computer applications
• Prior experience working in a medical office setting required
• Knowledge of Medical Terminology and good spelling/typing skills
• Intermediate computer skills using various software applications including Microsoft Word & Excel
• Experience in using Microsoft Office: Excel, Word, etc. Adobe Pro and demonstrated ability to learn/adapt to computer based tracking and data collection tools

How to write Medical Records Clerk Resume

Medical Records Clerk role is responsible for computer, medical, interpersonal, basic, organizational, customer, applications, software, training, records. To write great resume for medical records clerk job, your resume must include:

• Your contact information
• Work experience
• Skill listing

Contact Information For Medical Records Clerk Resume

The section contact information is important in your medical records clerk resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

• First and last name
• Telephone number

Work Experience in Your Medical Records Clerk Resume

The section work experience is an essential part of your medical records clerk resume. It’s the one thing the recruiter really cares about and pays the most attention to. This section, however, is not just a list of your previous medical records clerk responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular medical records clerk position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Medical Records Clerk resume experience can include:

• Good organizational skills, Ability to prioritize work and handle more than one task at a time
• Customer service and good telephone skills
• Have self-initiation and good follow-up skills
• Good organizational skills, results-driven and goal-oriented
• Sorting and counting skills
• Managing Work – effectively managing one’s time and resources to ensure that work is completed efficiently

Education on a Medical Records Clerk Resume

Make sure to make education a priority on your medical records clerk resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your medical records clerk experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

• School you graduated from
• Major/ minor
• Year of graduation
• Location of school

These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Medical Records Clerk Resume

When listing skills on your medical records clerk resume, remember always to be honest about your level of ability. Include the Skills section after experience.

Present the most important skills in your resume, there's a list of typical medical records clerk skills:

• Excellent interpersonal skills to deal effectively with research personnel
• Strong interpersonal skills that include the ability to effectively communicate verbally
• Enhances the skills and professionalism of the Department by sharing knowledge and experience gained from educational and training sessions
• Demonstrated competence in working effectively as a team member, as well as independently
• Strong organizational, multi-tasking, and customer service skills
• Good communication skills, ability to professionally interact with often difficult clientele

List of Typical Experience For a Medical Records Clerk Resume

Experience for medical records clerk g resume.

• Communicaiton skills; both written and verbal
• Operate telephone switchboard to answer, screen and forward calls; providing information, taking messages and forwarding calls to voicemail system
• Experience handling medical record request and inquiries
• Demonstrates courtesy and helpfulness towards staff
• Use good judgment in the course of contact with physicians, patients, staff and outside sources

Experience For Medical Records Clerk PRN / Seasonal Resume

• Ensuring that the records are being managed according to industry standards
• Prepping, Scanning and Analyzing medical records
• Preparing charts for scanning
• Maintaining and alphabetically filing medical records on a daily basis
• Typing 50-60 WPM, Lotus Notes, and thorough knowledge of various processing systems (MHS, CAPS, ICPS TOPPS, TOPS)
• Auditing medical records including follow-up on deficiencies
• Maintaining proper forms in charts required for community use

Experience For Medical Records Clerk, Mount Sinai Queens Resume

• Training of personnel for file room position
• Entering medical and financial information into databases
• Confirming with physicians or other medical personnel that the records are complete and correct
• Ensuring Electronic Medical Record health care data is accurate, complete and concise for data users
• Troubleshooting of all documentation
• Uploading documents to the EMR system

Experience For Medical Records Clerk Assistant Resume

• Willing to travel, at least twice a week, between 2-4 centers in KS and MO, if needed
• Scanning medical records into a digital record system
• Scanning and attaching medical records
• Organizing/filing of medical records
• Responsible for accessing, maintaining and auditing all medical charts; corrects and communicates problems according to established policies and procedures
• Assist in locating, retrieving, sending, and scanning requested medical records
• Provides clerical and administrative support to all Medical Records Unit activities such as purging paper charts and moving/packing boxes

Experience For Centralized Medical Records Clerk Resume

• Customer orientation - establishes and maintains relationships, building trust and respect by consistently meeting and exceeding expectations
• Proofread, copy documents, process incoming and outgoing mail, answer telephone and file
• Manage faxes as they come in; entering them into Brightree system and forwarding information to correct team
• Assists with sorting and putting away supplies/inventory
• Quality checking to ensure that each scanned document is of best possible quality, rescanning as appropriate

Experience For Zzz-medical Records Clerk Resume

• Determine Prime Record Location by reviewing DEERS before creating new records
• Audit filing system for missing or misplaced medical records
• Reach out to providers regarding missing information
• Maintain records of services and prepare billing documents submitted to appropriate agencies for facility reimbursement of health care costs
• Assist with new employee orientation and paperwork, maintenance of employee files, and ensuring HRIS systems are up to date
• Orders medical records, obtains missing authorization, and verifies that appropriate information is in the record

Experience For Medical Records Clerk, SCA Resume

• Ensures complete and accurate medical records by following up on inconsistencies and omissions with the appropriate personnel
• Stamps outgoing mail and delivers to mail box daily
• Mail- correspondence to referring physicians
• The type of clinician seen (physician, physician assistant, nurse practitioner, visiting specialist, external specialist, etc.)
• An International Classification of Diseases, 9th Revision (ICD-9) code classifying the medical conditions involved
• Greet persons entering organization, determine nature and purpose of visit and direct or escort them to specific destinations

Experience For Electronic Medical Records Clerk Resume

• Maintains all patient files; ensuring all delivery tickets, claims and patient paperwork are filed in the correct patient file
• Computer expereince, including Microsoft Office Suite
• Release of Information (fax, phone or mail) for all patient types following all hospital policies, State Privacy laws and HIPAA
• Answers telephone calls from physicians requesting rush transcription and checks the Digital Transcription System to locate STAT dictation
• Organizes and sorts transcribed reports according to type and processes
• Retrieve, deliver, and file health records daily for documentation team as needed; ensure that the guidelines for proper handling are met at all times
• Monitors central supplies and assists with maintaining supply room
• Complete tasks according to Medical Records policy
• 0 Retrieve medical records according to departmental procedures within the time frames established by supervisor for scheduled and unscheduled record requests

Experience For Principal Medical Records Clerk Resume

• 0 File medical records according to departmental procedure on a daily basis with 100% accuracy
• Indexes by accurately selecting document header sheet for documents that need to scan
• Performs concurrent scanning within determined time frames
• Rounds with facility collecting items to be processed
• Receive, review, and release patient medical information according to established standards of confidentiality and release of information

Experience For Metcare Medical Records Clerk Resume

• Forward files to appropriate departments, following appropriate charge-out procedure
• Responds to requests for information from files according to established policies and procedures
• Files and boxing batches of records to be sent away to storage facilities
• Assists with preparing data for requested reports
• Assists with departmental mailings, including patient medical records. Ensures accuracy of recipient contact information and location for correct delivery
• Responds to inquiries and assists staff and auditors/reviewers with locating medical documents in the chart
• Types memorandums, letter, and reports. Take minutes for the Medical Records/Utilization Review Committee meeting, type and distribute
• Keeps supervisor fully informed of activities, pertinent issues, upcoming events and potential problems assist hospital staff courteously and professionally

List of Typical Skills For a Medical Records Clerk Resume

Skills for medical records clerk g resume.

• Shows initiative enthusiasm, creativity, and good verbal and written communication skills
• One (1) year of medical records office experience or medical records training or acute hospital setting experience
• General data entry and computer skills. Basic understanding of computer processes and applications
• Problem solving skills to solve process problems
• Related experience in a healthcare/medical setting; or any combination of education and experience, which would provide an equivalent background
• Experience working with detailed information and a detailed process that requires strong attention to detail
• Proficient computer skills, including MS Office applications
• Competence in filing, telephone and clerical skills
• Prior experience in an office setting required

Skills For Medical Records Clerk PRN / Seasonal Resume

• Communicate efficiently and effectively both verbally and in writing
• Technical - Ability to effectively use Horizon Patient Folder, ADI, Meditech and other software programs required to complete job function
• Organizational skills with the ability to multi-task
• Proficient computer/data entry skills
• Knowledge of basic computer skills in order to enter and extract patient information
• High Interpersonal customer service and communication skills
• Accurate data entry skills- Knowledge of medical terminology required
• Maintains skills acquisition and data collection files
• Streamlining workflow resulting in more effective medical records keeping

Skills For Medical Records Clerk, Mount Sinai Queens Resume

• Reviewing intake charts for accuracy prior to scanning
• Confirming that all releases of information are current and valid
• Assists with gathering, processing & preparing charts/documentation needed prior to patient appointments or as part of follow-up
• Experience working in a medical records business office setting
• Experience performing medical records/health information functions in a health care setting (desired)
• Experience performing medical records/health information functions in a health care setting
• Skilled Nursing Facility in Manhattan looking for a medical records clerk to join their team as soon as possible
• MS Excel with formatting and developing spreadsheets experience

Skills For Medical Records Clerk Assistant Resume

• Experience in Medical Billing / Insurance practices and procedures
• Fax and photocopying experience helpful
• Office experience in a healthcare setting
• Clerical experience in an office setting
• One to two years related experience, preferably in a health care setting
• Demonstrates an understanding of patient/sponsor confidentiality to protect the patient and practice
• Assist in the guidance and training of less experienced staff

Skills For Centralized Medical Records Clerk Resume

• Microsoft Office: Excel, Word, etc. Adobe Pro and demonstrated ability to learn/adapt to computer based tracking and data collection tools
• Medical Records documentation or digital imaging experience
• Experienced with MS Word and Excel and ability to learning new computer programs
• Customer experience, ideally within a healthcare setting, required
• General Clerical experience in a Healthcare and/or Hospital environment

Skills For Zzz-medical Records Clerk Resume

• Excellent ability to perform tasks exactly as instructed
• Medical Records experience
• Two years of experience in medical records or related
• One year experience in medical general office environment required
• Operate and manipulate automated systems such as CHCS, AHLTA, MRRS and ESSENTRIS
• Interact and maintain good working relationships with individuals of varying social and cultural backgrounds
• Experience working in a call center or service center very helpful. High volume of phone work in this role
• Operate various work-processing software, spreadsheets, and database programs

Skills For Medical Records Clerk, SCA Resume

• Knowledge of clinical documentation layout and experience with Medical Records
• Operates high speed and desk top scanners
• Fice experience
• Operates computer to retrieve data and file signed correspondence and reports
• Reviews all the physician daily to ensure that all charts have been scanned and are complete prior to the patient’s appointment
• Computer experience: Excel, Word, Outlook, HST

Skills For Electronic Medical Records Clerk Resume

• Two – three years’ work experience in medical office, hospital or ambulatory surgery center
• Handle multiple tasks, set priorities and work independently
• Education, Experience, and Licensure
• Three to five years’ experience in medical office, hospital, outpatient surgery center or related field
• Clerical experience

Skills For Principal Medical Records Clerk Resume

• One (1) year of experience, preferably in an Ambulatory Surgery Center (ASC)
• Experience in Endoscopy/Multi-specialty/Ophthalmology/ASC
• Experience in Medical Records
• Database, CRT, PC experience
• Experience in medical records
• Recent Health Care or Health Plan experience
• Demonstrates flexibility, cultural sensitivity and ability to maintain confidentiality
• Strong attention to detail & ability to maintain confidentiality

Skills For Metcare Medical Records Clerk Resume

• Experience in an administrative role
• Medical records, administrative, office or patient registration experience (REQUIRED)
• Operate with limited direction
• Read, write, and communicate skillfully in English
• Demonstrated collaboration with peers
• Greater than 3 months of related experience
• At least one (1) year of medical records/EMR based experience

List of Typical Responsibilities For a Medical Records Clerk Resume

Responsibilities for medical records clerk g resume.

• Basic computer skills (data entry, word processing)
• Working knowledge of and ability to operate a personal computer
• Prioritize quickly and appropriately with minimal guidance
• Possess one year of experience in a field requiring regular usage of medical terminology or successful completion of a medical terminology course
• Willing to follow established procedures yet, be creative to offer suggestions for improvements
• Processes the doctor’s batch. This includes sorting and stapling by original, carbon, and corrected copies
• Requests are logged in/out in computer system for tracking & disclosure accounting
• Proficient with navigating and retrieving clinical information from an electronic medical record

Responsibilities For Medical Records Clerk PRN / Seasonal Resume

• Perform basic clerical functions (typing, filing, mail, etc.)
• Attend all scheduled meetings and required training
• Flags the dictation being charted for the physician’s signature
• Delivers documents to other nursing units as applicable
• Routes all prepped charts to proper location to be picked up by scanning company

Responsibilities For Medical Records Clerk, Mount Sinai Queens Resume

• Keeps chart dividers in order and places in proper location for re-use after prepping
• Assists with keeping ER’s filed in appropriate expandable folder by date
• Assists with making temporary colored folders for Inpatient and Outpatient charts as necessary
• Review medical record documentation to determine if the medical record is ready for coding
• Understand and apply different forms and rules depending on the record type
• Detail oriented, particularly with reading comprehension
• Process medical record requests received from outside sources and follow up on outstanding record requests
• Track records throughout the facility using Composite Healthcare Computer System

Responsibilities For Medical Records Clerk Assistant Resume

• Retrieve records for research, special studies, coding audits and for Joint Commission review
• Provide an average of 24,000 administrative support actions annually, performing an average of 4 actions and hour
• Establishes and maintains courteous, cooperative relations when interacting w/ other personnel and the public
• Notify appropriate personnel of malfunctioning equipment in a timely manner (printer, copiers, faxes, etc.)
• Travel – when traveling they need to know how to use a scanner and flash drive and be able to hook up a scanner
• Understand and apply current state and federal regulations regarding release of patient information
• Physical Abilities: Stand, walk, stoop and bend. Lift/ move/ carry files and folders weighing up to 30 pounds. See, hear, finger, grasp
• Formal training in basic medical record science

Responsibilities For Centralized Medical Records Clerk Resume

• Knowledge of JCAHO & Title 22 requirements for acute hospital setting
• Open to working a temporary position, 2-4 weeks
• Physically able to perform labor intensive tasks every day (lifting fo 40-50 lb boxes if necessary)
• Photocopy records and documents for billing and/or legal services
• Flexible to include the ability to handle diverse jobs under constantly changing conditions

Responsibilities For Zzz-medical Records Clerk Resume

• Knowledge of medical terminology, required procedures for releasing records
• Processes written and verbal requests for patients’ medical records as per established guidelines
• Pulls medical records for messages left for medical personnel or prescription requests. Routes patients’ medical documentation to home center as applicable
• Prepares packets for recertifications
• Discharge Analysis: Compile chart in discharge format and review for completeness. Notify appropriate staff members of any deficiencies. Prepare chart for closure
• Concurrent Review: Thin active inpatient charts, review for completeness, and notify staff of deficiencies. Thinned materials are to be stored in the Medical Records filing area
• Enter various data in Excel spreadsheets for tracking

Responsibilities For Medical Records Clerk, SCA Resume

• Participate in job-related educational activities
• Attend hospital and departmental staff meetings
• Orders supplies and forms as needed
• Creates new patient files for patients in all locations
• Match patient delivery tickets with eligibility forms
• Mail any off-cycle deliveries that can go regular mail as directed by Distribution
• Mail all Company correspondence; track all postage used via postage log
• Review and audit medical records
• Record discrepancies and update patient charts

Responsibilities For Electronic Medical Records Clerk Resume

• Ensure files are in line with compliance
• Scan and/or email patient files via client software
• Receive inbound calls from patients, attorney's, and insurance companies
• Create "new" patient folder for each patient using patient's unique hospital number or name, according to established department protocol; maintain master patient index; assist physicians with record completion; contact physicians regarding incomplete charts
• Deliver and retrieve patient records (hard copy or microfilmed) to emergency room, admission office or medical/surgical nursing unit; complete out-guide or use electronic device to identify patient record (MRN), date and name of individual requesting record
• Facilitate team work and demonstrate good organizational skills

Responsibilities For Principal Medical Records Clerk Resume

• Demonstrate proper operation of the telephone, fax machines, copiers and computers. Perform minor maintenance
• Maintain correspondence log; perform routine clerical tasks
• Responsibilities do not include direct patient care
• Assembles patients’ charts and updates patient profiles; files all medical reports and non-medical correspondence in patients’ charts; repairs damaged charts
• Maintains patients’ charts and files in compliance with established policies and procedures
• Answer the telephone promptly and according to established procedures, utilizing the utmost courtesy and sensitivity. Independently handles any call so as to minimize transfers. Accurately record messages and relay the verbal or faxed information in a timely manner
• Communicate effectively with co-workers, patients, and medical staff. Independently prioritizes workload and makes appropriate adjustments to accommodate changes in priorities
• Computer experience with (Excel, Power Point,Word)
• Make independent judgments and to solve basic operational problems

Responsibilities For Metcare Medical Records Clerk Resume

• Perform multiple tasks, and to appropriately deal with stress
• Maintain quality review of medical records
• Maintain the integrity of scanned records
• Audit Electronic Health Records
• Assists Director with problem areas as needed
• Policy and procedure review and creation

Related to Medical Records Clerk Resume Samples

Medical records resume sample, medical records technician resume sample, records clerk resume sample, enterprise data office resume sample, director, office resume sample, room supervisor resume sample, resume builder.

Resume Worded   |  Resume Skills

Skill profile, medical records specialist, improve your resume's success rate by using these medical records specialist skills and keywords ..

• Hard Skills and Keywords for your Medical Records Specialist Resume
• ATS Scan : Compare Your Resume To These Skills
• How To Add Skills
• Soft Skills for Medical Records Specialist Roles
• Medical Records Specialist More Resume Templates

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Looking for keywords for a specific job search for your job title here., © 2024 resume worded. all rights reserved., medical records specialist resume keywords and skills (hard skills).

Here are the keywords and skills that appear most frequently on recent Medical Records Specialist job postings. In other words, these are the most sought after skills by recruiters and hiring managers. Add keywords directly into your resume's work experiences , education or Skills section . Remember that every job is different. Instead of including all keywords on your resume, identify those that are most relevant to the job you're applying to. Use the free Targeted Resume tool to help with this.

• Medical Records
• Electronic Medical Record (EMR)
• U.S. Health Insurance Portability and Accountability Act (HIPAA)
• Medical Terminology
•  Find out what your resume's missing
• Healthcare Information Technology (HIT)
• Healthcare Management
• Medical Coding
• Medical Billing
• Epic Systems
• Patient Safety
• Current Procedural Terminology (CPT)
• Cardiopulmonary Resuscitation (CPR)
• Customer Service
• Health Information Management

Resume Skills: Medical Coding

• Medical terminology
•  Match your resume to these skills

Resume Skills: Medical Records Management

• Electronic Medical Records (EMR)
• International Classification of Diseases (ICD)
• Current Procedural Terminology (CPT) codes
• Health Information Portability and Accountability Act (HIPAA)

Resume Skills: Software Proficiency

• MS Office Suite
• EPIC Systems
• McKesson STAR 2000

Resume Skills: Technical

• Health Information Systems
• Records Management

Resume Skills: Languages

Resume skills: administration.

• Medical Records Management
• Patient Scheduling
• Insurance Verification

Resume Skills: Tech Tools

• MS Office (Word, Excel, PowerPoint)
• Google Docs
• EHR platforms

Resume Skills: Medical Billing

• Billing software
• Insurance verification
• Claims processing
• Reimbursement procedures
• Denials management

Resume Skills: Information Management

• EMR systems
• HIPAA compliance
• Confidentiality protocols
• Patient scheduling

Resume Skills: Software

• Microsoft Office (Excel, Word, PowerPoint)
• Database management

  Where on my resume do I add these buzzwords? Add keywords directly into your resume's work experiences , education or projects. Alternatively, you can also include a Skills section where you can list your technical skills in order of your proficiency. Only include these technical skills or keywords into your resume if you actually have experience with them.

   Does your resume contain all the right skills? Paste in your resume in the AI Resume Scan ↓ section below and get an instant score.

Compare Your Resume To These Medical Records Specialist Skills (ATS Scan)

Paste your resume below and our AI will identify which keywords are missing from your resume from the list above (and what you need to include). Including the right keywords will help you get past Applicant Tracking Systems (i.e. resume screeners) which may scan your resume for keywords to see if you're a match for the job.

Sample Medical Records Specialist Resume Examples: How To Include These Skills

Add keywords directly into your resume's work experiences , education or skills section , like we've shown in the examples below. use the examples below as inspiration..

  Where on my resume do I add these buzzwords? Add keywords directly into your resume's work experiences , education or projects. Only include these technical skills or keywords into your resume if you actually have experience with them.

How do I add skills to a Medical Records Specialist resume?

Go through the Medical Records Specialist posting you're applying to, and identify hard skills the company is looking for. For example, skills like Electronic Medical Record (EMR), Medical Records and Healthcare are possible skills. These are skills you should try to include on your resume.

Add other common skills from your industry - such as Medical Terminology, Data Entry and U.S. Health Insurance Portability and Accountability Act (HIPAA) - into your resume if they're relevant.

Incorporate skills - like Current Procedural Terminology (CPT), Customer Service and Cardiopulmonary Resuscitation (CPR) - into your work experience too. This shows hiring managers that you have practical experience with these tools, techniques and skills.

A good Medical Records Specialist has strong attention to detail, so try to include examples of where you handled complex projects or processes.

Try to add the exact job title, Medical Records Specialist, somewhere into your resume to get past resume screeners. See the infographic for how to do this.

Word Cloud for Medical Records Specialist Skills & Keywords

The following word cloud highlights the most popular keywords that appear on Medical Records Specialist job descriptions. The bigger the word, the more frequently it shows up on employer's job postings. If you have experience with these keywords, include them on your resume.

Medical Records Specialist Soft Skills

Here are common soft skills that appear on Medical Records Specialist job postings. Unlike hard skills, which refer to tools, software or techniques, soft skills focus on character traits and interpersonal skills. Instead of listing these phrases on your resume, try to show them through your bullet points like in the examples below.

Tip: Do not list these words or phrases on your resume, and instead focus on the hard skills we described above.

Get your Resume Instantly Checked, For Free

Upload your resume and we'll spot the issues in it before an actual medical records specialist recruiter sees it. for free., medical records specialist resume templates.

Here are examples of proven resumes in related jobs and industries, approved by experienced hiring managers. Use them as inspiration when you're writing your own resume. You can even download and edit the resume template in Google Docs.

Resume Example Entry Level Medical Coder

An effective Description of the templates...

Download this resume template

A medical coder is a healthcare information management professional. An entry level medical coder will work alongside tenured medical coders to ensure patient data is encrypted, secured, and organized. The job of the medical coder revolves around translating sensitive patient data into ambiguous codes for easy storage and simple retrieval. To get a job as an entry level medical coder, a Bachelor’s degree in medical informational technology, computer science, or healthcare administration is ideal. Hiring managers will like to see any relevant research projects, internships, or externships you have completed alongside your education. A part-time job in a healthcare setting, such as a role as a medical billing assistant, can also help you land an entry level medical coder role.

Tips on why this template works

   highlight relevant projects that relate to the role of a medical coder.

Being that this is an entry level job, hiring managers will be looking to see if you were engaging in concepts relevant to the position throughout your undergraduate career. A great way to showcase your knowledge in the field is to detail research papers or projects you’ve completed in college. Any project you’ve completed in information technology is valuable, but particularly if the subject matter was specific to medical coding.

   Showcase your knowledge with certificates

Certificates are a great way to enhance an entry level resume. Certifications like the CPC (Certified Professional Coder) and CMA (Certified Medical Auditor) show hiring managers you have specialized knowledge in the field of medical coding and are proficient in the subjects that will make you a great medical coder.

Resume Example Professional

This resume template is suitable for experienced hires or mid-level hires. The education contains two examples of an education experiences, but only include one (your most recent one) if you're a senior level employee.

   Makes great use of space

It strikes the right balance between white space and content, and doesn't waste space on unnecessary images and icons. Remember, recruiters aren't looking at how creative you are when it comes to your template. Your content is core and should be the focus.

   Strong resume bullet points

This job seeker uses resume bullet points that uses strong action verbs, and most importantly, contain numbers that demonstrate the significance of their accomplishments.

Resume Example Highlights (Free)

This template is clean, readable by resume screeners, and is effective at calling out key accomplishments and projects from specific work experiences. This would be useful if you have been at a company for a while, or been in a consulting-type of role, and want to point hiring managers to your most impressive accomplishments.

   Strong action verbs

Action verbs are important on your resume are vital. They evoke strong imagery to your reader, and this resume does an excellent job by using words such as “spearheaded,” “managed,” and “drove.” These words will help you to put your achievements in perspective, in conjunction with measurable results. Use action verbs relating to the skills you want to highlight.

   Specific examples of finished projects

Many of your accomplishments will involve your responsibilities in your employer's high-level projects. Recruiters want to see what you’ve completed in previous roles -- such as the Operations Improvement Project and new iPhone app launch highlighted in this resume. The numbers make your experience real, rather than a vague “oversaw several teams for a project.” What did you do specifically? Be specific.

Resume Example Modern Two-Column

This two column resume template has been designed and created in Google Docs, and puts an emphasis on a skills section. You can download it in Word, or edit it directly in Google Docs.

   Prioritize work experience, while including other key sections

The two-column in this Google Docs resume template prioritizes the work experience sections, while maximizing the content into the resume. Not all two column templates are ATS-compatible, but this one is when it is saved as PDF and passed through a resume screener.

   Includes a strong Skills section

Skills sections are a great way to include specific keywords and skills that you have, that haven't been included in other parts of your resume. This helps you get past resume screeners that scan your resume for specific keywords.

Resume Example Clean Modern

If you're a job seeker with a few years of experience under your belt, use a template like this one. It's simple, effective at highlighting our work experience, and minimizes the emphasis on the education section (the dates are omitted which is good to prevent ageism, especially if you graduated more than 10 years ago).

   Professionally-designed template

Minimal templates like this one are exactly what mid-to-senior level recruiters want to see - it shows professionalism, focuses on accomplishments, and makes full use of each page.

   Resume summary highlights key accomplishments

The first rule about including a resume summary is that it does not repeat accomplishments mentioned elsewhere on the resume. This resume stresses new software engineering and leadership skills right at the top of the resume, and includes an award too. If you include a summary, try to include a mix of both technical accomplishments (e.g. projects you developed or led), as well as career-related accomplishments (e.g. being promoted).

Resume Example Entry-Level (Free)

Use this Google Docs template if you're a student, recent graduate, or a career changer. Right out of college, you may not have much experience in the field. To supplement that, use your experience in clubs and activities, volunteering, projects, and useful coursework to help highlight your knowledge on the subject.

   Emphasis on education

If you're an entry-level job seeker that has recently completed education (or in the process of completing a degree), you should prioritize your education and include it first. This Google Docs template does this.

   University projects relevant to the job

If you're an entry level job seeker (or a career-changer), you may not have enough work experience to fill up your resume. This is where class projects and university projects come in. This template has a section dedicated to projects, which you can use to talk about volunteering, class projects, or personal projects relevant to the job.

What skills do hiring managers want to see on a Medical Records Specialist resume?

The most common skills and keywords we found on Medical Records Specialist resumes and job postings were Medical Records, Electronic Medical Record (EMR), U.S. Health Insurance Portability and Accountability Act (HIPAA), Medical Terminology, Healthcare, Hospitals, Data Entry and Healthcare Information Technology (HIT). Skills like Customer Service, Cardiopulmonary Resuscitation (CPR), Health Information Management, Healthcare Management and Current Procedural Terminology (CPT) also appeared on related job postings.

Target your Resume to a Job Description

While the keywords above are a good indication of what skills you need on your resume, you should try to find additional keywords that are specific to the job. To do this, use the free Targeted Resume tool. It analyzes the job you are applying to and finds the most important keywords you need on your resume. It is personalized to your resume, and is the best way to ensure your resume will pass the automated resume filters. Start targeting your resume

Most resumes get auto-rejected because of small, simple errors. These errors are easy to miss but can be costly in your job search. If you want to make sure your resume is error-free, upload it to Score My Resume for a free resume review. You'll get a score so you know where your resume stands, as well as actionable feedback to improve it. Get a free resume review

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Find out what keywords recruiters search for. These keywords will help you beat resume screeners (i.e. the Applicant Tracking System).

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The safety of outpatient health care: review of electronic health records.

Levine DM, Syrowatka A, Salmasian H, et al. The safety of outpatient health care: review of electronic health records. Ann Intern Med. 2024;Epub May 7. doi:10.7326/m23-2063.

Although most care occurs in outpatient settings, research into adverse events (AE) in this setting remains sparse in comparison to acute care. In this study, the medical records of patients who received outpatient care (e.g., primary, radiology , emergency, ambulatory surgery) in Massachusetts in 2018, were reviewed for any occurrence of adverse events. Seven percent had at least one AE, most commonly adverse drug events , and 23% were potentially preventable. Most AE originated from care in the physician's office.

The safety of inpatient health care. January 25, 2023

Expert consensus on currently accepted measures of harm. September 9, 2020

An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting. December 8, 2021

Key use cases for artificial intelligence to reduce the frequency of adverse drug events: a scoping review. March 9, 2022

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022

Families as partners in hospital error and adverse event surveillance. March 8, 2017

Optimizing Pediatric Patient Safety in the Emergency Care Setting. October 19, 2022

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. March 16, 2016

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems. May 1, 2019

Incorporating medication indications into the prescribing process. May 9, 2018

Medication-related clinical decision support alert overrides in inpatients. November 15, 2017

Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors. October 19, 2016

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit. May 10, 2017

An examination of medical malpractice claims involving physician trainees. August 19, 2020

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021

High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events. May 20, 2020

Ten principles for more conservative, care-full diagnosis. October 10, 2018

Long-term sustainability and adaptation of I-PASS handovers. September 13, 2023

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems. May 24, 2017

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting. April 6, 2016

Changes in medical errors after implementation of a handoff program. November 12, 2014

A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors. June 27, 2018

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool. May 15, 2013

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement. May 25, 2016

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. August 16, 2017

Electronic health records and malpractice claims in office practice. December 3, 2008

Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program. February 1, 2023

How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions. July 10, 2019

Patient activation related to fall prevention: a multisite study February 19, 2020

The potential of artificial intelligence to improve patient safety: a scoping review. March 31, 2021

Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs. June 27, 2018

Patient safety indicators during the initial COVID-19 pandemic surge in the United States. March 27, 2024

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit. January 23, 2019

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit. February 28, 2018

Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial. May 29, 2019

Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling. March 6, 2019

Readiness of US general surgery residents for independent practice. October 4, 2017

Preventing home medication administration errors. March 14, 2022

Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. January 25, 2023

Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use? January 11, 2012

Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems. September 4, 2019

Overrides of medication-related clinical decision support alerts in outpatients. January 8, 2014

Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation. December 18, 2019

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011

Screening for medication errors using an outlier detection system. February 8, 2017

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. May 23, 2012

Association of display of patient photographs in the electronic health record with wrong-patient order entry errors. December 2, 2020

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review. January 12, 2022

Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial. December 2, 2020

Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. August 21, 2013

Role of pharmacist counseling in preventing adverse drug events after hospitalization. March 22, 2006

Effect of genetic diagnosis on patients with previously undiagnosed disease. November 7, 2018

The vulnerabilities of computerized physician order entry systems: a qualitative study. December 9, 2015

Extended work shifts and neurobehavioral performance in resident-physicians. March 10, 2021

Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists. October 13, 2021

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population. August 3, 2022

Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study. May 24, 2017

The impact of racism on child and adolescent health. July 1, 2019

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care. May 4, 2022

Four-year impact of an alert notification system on closed-loop communication of critical test results. November 26, 2014

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. April 29, 2009

Conducting safety research safely: a policy-based approach for conducting research with peer review protected material. January 13, 2021

Impact of vendor computerized physician order entry in community hospitals. February 22, 2012

Safety culture and mortality after acute myocardial infarction: a study of Medicare beneficiaries at 171 hospitals. October 25, 2017

Operational failures detected by frontline acute care nurses. March 29, 2017

Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application. June 13, 2018

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. January 28, 2015

Effect of bar-code technology on the safety of medication administration. May 12, 2010

Ambulatory prescribing errors among community-based providers in two states. December 21, 2011

Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. December 11, 2013

Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023

A randomized trial of a multifactorial strategy to prevent serious fall injuries. July 29, 2020

Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023

An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response. March 19, 2008

Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department. May 30, 2018

Crisis checklists for the operating room: development and pilot testing. January 30, 2005

A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts. December 7, 2022

Using incident reporting to improve patient safety: a conceptual model. March 28, 2007

The Veterans Affairs National Quality Scholars Program: a model for interprofessional education in quality and safety. August 22, 2012

Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals with improved outcomes. February 7, 2024

Toward improving patient safety through voluntary peer-to-peer assessment. January 25, 2012

Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial. July 15, 2020

Effect on patient safety of a resident physician schedule without 24-hour shifts. July 15, 2020

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. March 10, 2010

Diagnostic concordance among pathologists interpreting breast biopsy specimens. March 25, 2015

Adverse events in hospitalized pediatric patients. July 25, 2018

Physicians and electronic health records: a statewide survey. March 21, 2007

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. August 25, 2010

Factors determining safety culture in hospitals: a scoping review. October 25, 2023

The impact of automated notification on follow-up of actionable tests pending at discharge: a cluster-randomized controlled trial. April 11, 2018

Large-scale implementation of the I-PASS handover system at an academic medical centre. March 22, 2017

Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement. September 2, 2015

Impact of sleep deficiency on surgical performance: a prospective assessment. April 19, 2023

Improving patient safety in intensive care units in Michigan. June 25, 2008

Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts. February 17, 2021

Education outcomes from a duty-hour flexibility trial in internal medicine. March 28, 2018

Stranded in the ER, seniors await hospital care and suffer avoidable harm. May 15, 2024

WebM&M Cases

The association between nurse staffing and quality of care in emergency departments: a systematic review. March 20, 2024

Patient reasoning: patients' and care partners' perceptions of diagnostic accuracy in emergency care. January 10, 2024

Nurses' experience with presenteeism and the potential consequences on patient safety: a qualitative study among nurses at out-of-hours emergency primary care facilities. January 10, 2024

Overnight stay in the emergency department and mortality in older patients. November 29, 2023

Network of Patient Safety Databases Chartbook. November 8, 2023

Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review. October 25, 2023

"You just want to feel safe when you go to a healthcare professional:" intimate partner violence and patient safety. August 2, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Annual Perspective

Reducing diagnostic errors in the emergency department at the time of patient treatment. March 29, 2023

Near-miss events detected using the emergency department trigger tool. March 15, 2023

Perspective

Journal Article

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Emergency department adverse events detected using the emergency department trigger tool. August 24, 2022

The frequency and nature of prescribing problems by general practitioners in training (REVISiT). June 15, 2022

Diagnostic trajectories in primary care at 12 months: an observational cohort study. June 15, 2022

Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study. May 18, 2022

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study. May 11, 2022

Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review. January 26, 2022

SECUre: a multicentre survey of the safety of emergency care in UK emergency departments. November 24, 2021

Incidence of prescription errors in patients discharged from the emergency department. September 22, 2021

Adverse events in emergency department boarding: a systematic review. August 18, 2021

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility. July 21, 2021

Experiences of transgender and gender nonbinary patients in the emergency department and recommendations for health care policy, education, and practice. July 21, 2021

Moving beyond the weekend effect: how can we best target interventions to improve patient care? June 30, 2021

Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1). May 5, 2021

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Your doctor (and ChatGPT) will see you now. A peek into AI-assisted medical visits.

Generative ai and chatbots offer promise for medical visits.

BOSTON ‒ Dr. Rebecca Mishuris remembers her mother, also a doctor, bringing home her patients' medical charts every night and working on them long after she'd gone to bed.

For years, Mishuris, a primary care physician at Brigham and Women's Hospital, repeated the ritual herself.

But no more.

Since last summer, she's been piloting two competing software applications that use large-language models and generative artificial intelligence to listen in on, transcribe and summarize her conversations with patients. At the end of a patient visit it takes her just two to three minutes to review the summary for accuracy, cut and paste a few things into the patient's health record and hit save.

"I look at my patients now (during a visit)," said Mishuris, who oversees the pilot project across 450 Mass General--Brigham-affiliated providers and plans to expand to 800 within the next month. "It's a technology that puts me back in the room with my patient as opposed to putting up a barrier between me and the patient."

Mishuris, chief medical information officer and vice president of digital at Mass General Brigham, is among the earliest adopters of artificial intelligence in medicine, a field known for being slow to adapt to change. ("Legit, there's a fax machine at the front of my clinic," she said.)

While some other doctors have incorporated AI and large-language models, such as ChatGPT that analyze reams of online language, into their practices, Mishuris and a team 200 miles away at NYU Langone Health are among the few who have opted to study its use.

They want to ensure the technology improves overall care before they adopt it more widely.

"We're not racing to get this out there. We really are trying to take a measured course," said Dr. Devin Mann, strategic director of digital innovation at NYU Langone's Medical Center Information Technology. "We really like to understand how these tools really work before we let them loose."

The much-maligned electronic health record

No one wants to make a mistake that will lose the trust of patients or doctors when using this technology.

After all, digital technology has disappointed both before.

Electronic health records have become essential tools in medicine, replacing the rooms full of paper documents that were hard to maintain and subject to fires and other losses.

But patients hated the shift to electronic health records.

Rather than building a relationship with a physician, they felt they were now talking to the back of a caregiver's head as they listened to clacking fingers rather than making eye contact and listening to the murmurs of someone paying close attention.

Doctors disliked them even more.

Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association, calls the shift to electronic health records the "great work transfer." Physicians, rather than nurses, medical assistants or clerical workers, were suddenly responsible for recording most of their patients' data during clinic visits.

In a 2016 study, Sinsky and her colleagues showed that after "the great work transfer," doctors were spending two hours on desk work for every hour face-to-face with patients.

"It is time on (electronic health records) and particularly time on physician order entry that is a source of burden and burnout for physicians," she said.

Burnout hurts everyone

Burnout leads to medical errors, increases malpractice risk, reduces patient satisfaction, damages an organization’s reputation and reduces patients’ loyalty, according to Sinsky, who worked as a general internist in Iowa for 32 years.

She calculated the cost of a doctor leaving the profession due to burnout at $800,000 to $1.4 million per physician. The lost funds include the cost of recruitment, a sign-on bonus and onboarding costs.

In a recent survey of doctors, nurses and other health care workers conducted by the AMA, nearly 63% reported symptoms of burnout at the end of 2021, up from 38% in 2020.

Inbox work also contributes to burnout, Sinsky said.

The volume of inbox work rose 57% in March 2020, as the pandemic set in, "and has stayed higher since that time," Sinsky said. Meanwhile, the rest of their workload hasn't dropped to compensate for the increase, so physicians are working more during their off hours, she said.

The amount of time doctors put in during their personal time ‒ commonly called "work outside of work" or "pajama time" ‒ is often a good predictor for burnout. Doctors in the top quarter of pajama-time workers are far more likely to feel burnout than those in the lowest quarter.

Among the other new requirements adding to burnout is the expectation doctors will be "texting while doctoring" ‒ typing throughout a medical visit. This experience is as deeply unsatisfying for the doctor as it is for the patient, Sinsky said.

Note-taking means synthesizing

Still, she's not convinced that generative AI and large-language models are the only or best solution to all these problems.

In her former practice, Sinsky said, what worked well was having a nurse in the room with the physician, sharing information, pulling up additional information from the electronic health record and entering orders in real time. That way, the doctor can focus on the patient and the nurse will be familiar enough with the patient's care to answer most follow-up questions that may arise between visits.

"When we build systems that synthesize care and consolidate care and prioritize the relationships among the people ‒ between the doctor and the patient, between the doctor and the staff ‒ that's when the magic happens. That's when quality is better, cost is lower," she said. "I see AI as a technology solution to a technology problem and its balance of risks and benefits hasn’t yet been determined."

Sinsky said she worries that something will be lost when doctors completely stop dictating or writing their own notes.

As anyone who writes regularly knows, it is in the act of writing that you truly begin to understand your subject, she said. Without that connection, that requirement to synthesize the material, Sinsky worries doctors will miss clues about their patients' health.

"How much (AI) is going to help and how much it's going to distract us, that's TBD," she said. "I fear that some physicians may just accept the AI output and not have that pause and that reflection that then helps you consolidate your understanding."

Offers of hugs and other signs of promise

Still, early responses to the AI notetaking technology from Mass General Brigham and NYU Langone have been positive.

"Some people say it's okay, but maybe not for them," Mishuris said, while most are more effusive. Many have reported "drastic changes in their documentation burden," saying in some cases that they've been able to leave their clinic for the first time without paperwork hanging over them, she said. "I've had people offer to hug me."

Mishuris' study also measures how much time doctors spend on their visit notes, in the electronic health records after clinical hours, and how much they change the AI-drafted notes. If the doctor makes a lot of changes, it suggests they are unhappy with the drafted note.

Each doctor participating in the study fills out a survey after using one of two technologies for two weeks, then after eight weeks and again at three months. At this point, participants are just about to hit the 8-week mark, so the data about burden and burnout is coming soon, Mishuris said.

She hopes studies like hers will determine whether the technology is useful and for whom. "It might be that the technology is not right for an oncologist yet," she said, or maybe it's not appropriate for every visit, "but that is what we're trying to determine."

At NYU Langone, where the AI experiment is happening on a smaller scale, early results show the technology was able to translate visit notes, which doctors typically write at a 12th grade level or above, to a 6th grade level ‒ which is more understandable to patients, said Dr. Jonah Feldman, medical director of clinical transformation and informatics for Langone's Medical Center Information Technology.

When the doctors wrote the notes, only 13% broke the content into simple chunks, while 87% of the Chat-GPT4 notes were written in easy-to-understand bits, he said.

Feldman said the goal of using AI is not to put anyone out of work ‒ typically the greatest fear workers have about artificial intelligence ‒ but to get more done in the limited time allotted.

That will allow doctors to spend more quality time with patients – hopefully improving interactions and care and reducing burnout, he said. “We’re focusing on making the doctor more efficient, making the experience in the room better,” Feldman said.

Mann, who oversees digital innovation at NYU Langone, said he hopes to avoid AI-written notes that read awkwardly and waste clinicians' time on "double-work," spending more time rewriting notes than they would have spent writing them in the first place. For this to work, he said, "It's got to be a lot better, a lot easier."

The Langone team is also experimenting with using AI to respond to patients' emails. Mann said providers want the email to sound personalized, so a doctor who previously would have sent patients "haikus" doesn't suddenly start sending "sonnets."

Next, the team wants to expand to home monitoring, so that someone who has been instructed, say, to check their blood pressure at home every day and upload that information to their doctor, can get questions answered via AI, rather than "chasing us down with phone tag," Mann said. "A lot of quick answers can be done faster, so we can put our limited time and energy into more complicated things."

He's also focused on providing these kinds of services first to people with limited resources since they are often the last to receive technological advances.

Ultimately, the success of this kind of technology will come down to whether doctors are willing to adopt it and patients are comfortable with it.

A recent Mishuris patient, Rachel Albrecht, had no problem with AI listening in on her medical appointment.

"It sounds like a good tool," Albrecht, 30, an accountant from Boston, said at the end of her appointment. She liked the idea of getting an easy-to-understand summary of results after a visit. "I'm pro-AI in general."

Karen Weintraub can be reached at [email protected].

Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released.

Volume 30, Number 6—June 2024

Electronic Health Record–Based Algorithm for Monitoring Respiratory Virus–Like Illness

Suggested citation for this article

Viral respiratory illness surveillance has traditionally focused on single pathogens (e.g., influenza) and required fever to identify influenza-like illness (ILI). We developed an automated system applying both laboratory test and syndrome criteria to electronic health records from 3 practice groups in Massachusetts, USA, to monitor trends in respiratory viral–like illness (RAVIOLI) across multiple pathogens. We identified RAVIOLI syndrome using diagnosis codes associated with respiratory viral testing or positive respiratory viral assays or fever. After retrospectively applying RAVIOLI criteria to electronic health records, we observed annual winter peaks during 2015–2019, predominantly caused by influenza, followed by cyclic peaks corresponding to SARS-CoV-2 surges during 2020–2024, spikes in RSV in mid-2021 and late 2022, and recrudescent influenza in late 2022 and 2023. RAVIOLI rates were higher and fluctuations more pronounced compared with traditional ILI surveillance. RAVIOLI broadens the scope, granularity, sensitivity, and specificity of respiratory viral illness surveillance compared with traditional ILI surveillance.

Respiratory viral illnesses place an enormous burden on human health and the healthcare system ( 1 – 3 ). Although multiple pathogenic respiratory viruses circulate, often simultaneously, public health has traditionally dedicated most of its attention to monitoring trends in laboratory-confirmed influenza and influenza-like illness (ILI). Illness and death associated with seasonal respiratory syncytial virus (RSV) spikes, the SARS-CoV-2 pandemic, and occasional clusters of infection from other respiratory pathogens, however, illustrate the importance of expanding monitoring to include all respiratory viral–like illness activity. Relying on laboratory testing alone will not accomplish this goal because most persons with respiratory viral illnesses do not seek care, many who do seek care are not tested, and not everyone tested is tested for all respiratory viruses.

Public health agencies have traditionally relied on syndromic surveillance to monitor conditions for which testing rates are low and variable ( 4 ). The Centers for Disease Control and Prevention’s outpatient Influenza-like Illness Surveillance Network and emerging systems designed to monitor COVID-19–like illness are prime examples ( 5 – 9 ). However, syndromic surveillance systems tend to provide little or no information about which particular pathogens are circulating, and most jurisdictions require fever to define ILI, a requirement that increases specificity but lowers sensitivity (fever occurs in fewer than half of persons with laboratory-confirmed influenza) ( 10 ). Surveillance focusing on single pathogens (e.g., influenza, SARS-CoV-2), viral testing alone, or syndromic definitions alone provides an incomplete picture of respiratory illness activity and can miss critical trends and developments ( 11 , 12 ). Extending surveillance to include multiple pathogens, using both laboratory testing and syndromes, and decreasing reliance on fever as a gatekeeper symptom are necessary to provide public health agencies and healthcare institutions with the data needed to improve situational awareness for planning, resource use, internal and external communications, and targeted prevention activities.

To regularly monitor overall respiratory viral illness activity associated with multiple pathogens, we developed an integrated surveillance strategy using a combination of laboratory and syndromic indicators, incorporating logic to identify the relative contributions of different individual pathogens. We describe our data-driven approach to developing a routine, automated respiratory virus-like illness (RAVIOLI) algorithm for syndromic surveillance in Massachusetts using live electronic health record (EHR) data drawn from 3 large practice groups. Our work was performed as public health surveillance and therefore not subject to institutional review board oversight.

We used the Electronic Medical Record Support for Public Health (ESP, https://www.esphealth.org ) public health surveillance platform to develop the RAVIOLI algorithm. ESP is open-source software that uses automated daily extracts of EHR data to identify and report conditions of public health interest to health departments ( 13 – 17 ). ESP maps raw data to common terms and then applies algorithms to identify conditions using diagnosis codes, prescriptions, laboratory tests, and vital signs. In Massachusetts, ESP is used for automated reporting of infectious disease cases to the Massachusetts Department of Public Health, aggregate reporting of chronic diseases, and continuum-of-care assessments ( 18 – 21 ).

Three multisite clinical practice groups that use ESP for infectious disease reporting, Atrius Health, Cambridge Health Alliance, and Boston Medical Center, contributed data for our project. Atrius Health ( https://www.atriushealth.org ) is an ambulatory care group with >30 locations in eastern Massachusetts that provides clinical services for a population of ≈700,000. Cambridge Health Alliance ( https://www.challiance.org ) is a safety-net system that provides ambulatory and inpatient care to >140,000 patients in communities north of Boston. Boston Medical Center ( https://www.bmc.org ) is a 514-bed academic medical center and safety-net hospital that provides ambulatory and inpatient care to ≈220,000 persons. We combined data from those 3 sites for this analysis.

We sought to develop an evidence-based set of diagnosis codes to identify respiratory virus–like illnesses and assess whether a subset of those codes might be predictive of specific pathogens. To identify codes associated with respiratory viral illness syndrome, we identified all patients tested for respiratory viruses ( Table 1 ) during October 3, 2015–July 30, 2022. Among patients who tested positive for > 1 virus, we identified all International Classification of Diseases, 10th Revision (ICD-10), diagnosis codes recorded within 2 days before or after the specimen collection date. For patients without a recorded specimen collection date, we used the test order date; if that was unavailable, we used the result date. We manually removed ICD-10 codes unrelated to respiratory viral illness (e.g., trauma, cancer, chronic disease management). The list of >7,000 excluded codes is available upon request from the authors.

We calculated the positive predictive value (PPV) for each ICD-10 code associated with positive respiratory virus test results. We also calculated the PPV for measured temperature >100°F within 2 days before or after a positive respiratory virus test. We calculated the PPV for each ICD-10 code and fever as the number of encounters with the diagnosis code within 2 days of a positive test divided by the total number of times the diagnosis code occurred across 
all clinical encounters during the study period. We defined a clinical encounter as a patient receiving a relevant diagnosis code, immunization, vital sign measure, laboratory test, or prescription.

We included in the final algorithm diagnosis codes with a PPV ≥10% for any respiratory virus (all viruses combined) or for a specific individual respiratory virus. We also included encounters with positive respiratory virus tests in the total count of respiratory virus encounters as well as in virus-specific categories of RAVIOLI. We counted each viral encounter only 1 time if the patient had both a positive respiratory virus assay result and > 1 suggestive diagnosis code. We classified measured fever alone and diagnosis codes with a PPV of ≥10% for any positive respiratory virus test but <10% for any specific respiratory virus in a category referred to as nonspecific for respiratory viral illness syndrome. In summary, we categorized positive cases within RAVIOLI as virus-specific (e.g., influenza, adenovirus), based on a positive test or a diagnosis code with a PPV ≥10% for the specific virus, or nonspecific, based on fever or a diagnosis code with a PPV ≥10% for any positive test of interest.

To better understand the underlying data included in the final RAVIOLI algorithm, we examined the proportion of patients in each virus-specific category of the algorithm with a positive laboratory test and the proportion of patients in the nonspecific category with a fever. We generated weekly counts during October 3, 2015–January 13, 2024, for clinical encounters with patients meeting the RAVIOLI algorithm, overall and stratified by the probable etiology when possible. For comparison, we also identified the proportion of patients that met the definition of ILI: fever and a diagnosis code for any influenza-like symptom or diagnosis; fever was identified by either a measured fever >100°F or diagnosis code for fever ( Appendix Table 1 ).

Figure 1 . Numbers of patients with a clinical encounter for respiratory virus–like illness and the percentages that met the requirements for influenza-like illness versus those of the RAVIOLI algorithm for monitoring respiratory...

Forty-two diagnosis codes ( Table 2 ) and measured fever (>100°F) had a PPV ≥10% for either any positive respiratory virus test (nonspecific) or > 1 virus-specific positive test; those diagnosis codes and fever are included in the RAVIOLI algorithm. We recorded weekly counts of patients with clinical encounters and calculated the proportion that met the definition for RAVIOLI overall (diagnosis code, fever, or positive respiratory virus test) and, for comparison, the proportion that met the ILI criteria ( Figure 1 ). The percentage of encounters that met the RAVIOLI algorithm showed clear seasonal trends of annual winter spikes during 2015–2019 followed by periodic increases during spring 2020–early 2024, corresponding to emergence or surges of SARS-CoV-2, RSV, and influenza in Massachusetts. RAVIOLI was identified in a much larger proportion of encounters than ILI after March 2020 and, at times (e.g., fall 2021, August–November 2023), ILI did not detect an increase in respiratory virus illness while RAVIOLI did.

Figure 2 . Numbers of patients that met the requirements for the RAVIOLI algorithm for monitoring respiratory virus–like illness, by pathogen category and week, Massachusetts, USA, October 2015–January 2024. A) October 2015–January 2024;...

• Figure 3 . Percentage of patients meeting the RAVIOLI algorithm for monitoring respiratory virus–like illness, by age group, Massachusetts, USA, October 2015–January 2024.

We estimated weekly counts of patients with clinical encounters meeting the RAVIOLI algorithm stratified by encounters with virus-specific or nonspecific encounters without a classified virus. We calculated those data for the full study period, October 2015–January 2024 ( Figure 2 , panel A), and for January 2020–January 2024 ( Figure 2 , panel B). Before March 2020, most RAVIOLI encounters came from the influenza or unclassified categories. SARS-CoV-2 subsequently dominated until fall 2021, when the nonspecific category reemerged, along with influenza and RSV. When we examined trends by patient age groups, the highest proportion of encounters that met the RAVIOLI algorithm were among children 0–4 years of age, followed by young persons 5–24 years of age ( Figure 3 ).

Data from January 2023–January 2024 show the proportions of patients in the COVID-19, influenza, and RSV categories with a positive laboratory test versus diagnosis code, as well as the proportion in the nonspecific with fever category ( Appendix Table 2 ). The proportion with a positive test varied by virus and time; patients in the COVID-19 category were least likely and those in the RSV category most likely to have a positive laboratory test. Among patients in the nonspecific category, one third or fewer had evidence of fever, and most were identified by a diagnosis code. We also determined the proportion of RAVIOLI patients identified on the basis of > 1 positive laboratory test, diagnosis code, or fever during January 2021–January 2024 ( Appendix Figure 1 ); RAVIOLI patients can meet > 1 criterion (e.g., have both a positive laboratory test and a diagnosis code). Diagnosis codes were the most common element contributing to identification in most weeks, followed by positive laboratory tests and fever.

Respiratory viruses continue to impose a high burden on patients, healthcare providers, and society, and multiple pathogens, including SARS-CoV-2, influenza, RSV, and others, contribute to the burden of respiratory illnesses. Both healthcare providers and public health agencies therefore have an interest in having access to timely and granular data on trends in respiratory viral illnesses and contributing pathogens. We developed an EHR-based algorithm for integrated surveillance of respiratory virus illness syndromes and associated pathogens using historical data to identify diagnosis codes and other characteristics of healthcare visits most predictive of confirmed respiratory viral illnesses. The RAVIOLI algorithm comprises positive laboratory tests, evidence-based diagnosis codes, and measured fever.

We have implemented RAVIOLI surveillance within the ESP automated public health surveillance platform to provide the Massachusetts Department of Public Health and participating practices with weekly reports on RAVIOLI incidence and contributing pathogens. RAVIOLI provides the department and practices with granular insight into evolving trends in respiratory viral illness rates that both retains the best features of traditional syndromic surveillance (capacity to monitor changes in disease incidence in near real time regardless of whether persons get tested) and simultaneously broadens the scope of surveillance to include multiple pathogens, not just influenza and SARS-CoV-2. The data provide insight into the relative proportions of contributing pathogens across multiple clinical facilities using both test results and diagnosis codes to identify organisms.

When implemented well, syndromic surveillance provides a picture of the frequency, intensity, and trends in indicators of infectious and noninfectious conditions at local and extended scales. Integrating available viral pathogen test results, even if only in a subset of the population under surveillance, as we have done with the RAVIOLI algorithm, can add information about what is or is not contributing to observed increases in respiratory viral activity. Although Influenza-like Illness Surveillance Network–defined and COVID-like illness surveillance have been critical components for monitoring influenza and COVID-19 activity, reliance on fever as a required component of syndromic definitions is problematic because fever occurs only in a minority of laboratory-confirmed influenza and SARS-CoV-2 cases ( 22 – 24 ). Syndromic surveillance algorithms that require fever can therefore miss critical trends in the incidence of illnesses ( 9 ). The RAVIOLI algorithm, in contrast, does not require fever as a criterion and uses both laboratory test results and an evidence-based set of diagnosis codes to increase both sensitivity and specificity.

Limitations of RAVIOLI surveillance include its development in a single region of the country using data from just 3 practice groups. Generalizability to other practice groups and regions need to be assessed. Changes in testing practices or coding practices over time and between practices might change the future performance of the RAVIOLI algorithm. The algorithm will require periodic revalidation and possibly modification. Furthermore, the breadth of pathogen capture using the RAVIOLI algorithm depends on the range and frequency of respiratory viral testing by clinicians; greater use of multiplex testing platforms will provide more granular and robust results. RAVIOLI surveillance is limited to patients who seek care, which likely biases the data toward pathogens associated with more severe disease. The PPV of algorithm components may vary by season; whether and how this affects surveillance should be considered. We used a 10% PPV threshold to select diagnosis codes for inclusion. This threshold was arbitrary, but we found using higher thresholds dramatically reduced the number of eligible diagnosis codes. We also found that the terms associated with diagnosis codes with a PPV of ≥10% were specific in their descriptions and not indicative of broad health conditions. However, the PPV threshold for including diagnosis codes should be considered in future revalidation of the algorithm.

The healthcare site data included in developing the algorithm and whose data are part of the weekly reports came from both ambulatory and inpatient care facilities. We observed variation in which RAVIOLI categories (e.g., influenza, RSV) of the algorithm were detected at each site (data not shown). The limited number of sites makes it difficult to know if apparent differences between ambulatory and inpatient sites resulted from differences in catchment populations, illness severity associated with different viruses, or testing platforms. As the network expands to include a greater number and variety of sites, we plan to examine this question further.

The Massachusetts Department of Public Health has used data from the underlying EHR-based system for infectious disease reporting and surveillance for more than a decade ( 18 – 21 , 25 – 28 ). This system has been sustained and enhanced over time to meet MDPH needs. As public health agencies consider what they need for the monitoring of current, emerging, and as-yet unidentified pathogens, we have found that a robust EHR data platform is a critical complement to traditional surveillance data.

In conclusion, we developed an integrated, routine, automated EHR-based system for respiratory virus surveillance in Massachusetts. As experience with this approach expands, the hope is that this system will provide early indications of emerging infection trends and prevailing pathogens that render a fuller picture of respiratory viral activity beyond ILI and COVID-like illnesses. A broader view of circulating pathogens will provide public health agencies and healthcare institutions with more precise information useful for informing testing guidance, optimizing health communications; developing more targeted prevention activities, including vaccination; initiating enhanced infection control measures, such as masking and posting of notices in facilities; and generating other policies optimized to minimize the effect on population health of specific circulating pathogens.

Dr. Cocoros is a principal research scientist at the Harvard Pilgrim Health Care Institute and a principal associate in the Department of Population Medicine. Her primary research interests include infectious disease epidemiology, pharmacoepidemiology, and the use of electronic health data for research and surveillance, from pandemic response to pragmatic trials.

Acknowledgments

The authors thank the following colleagues for their contributions: Kelly O’Keefe, Myfanwy Callahan, Dan Flanagan, Jonathan Bress, Brian Herrick, and Michelle Weiss.

This work was supported with funding from the Massachusetts Department of Public Health.

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• Figure 1 . Numbers of patients with a clinical encounter for respiratory virus–like illness and the percentages that met the requirements for influenza-like illness versus those of the RAVIOLI algorithm for monitoring...
• Figure 2 . Numbers of patients that met the requirements for the RAVIOLI algorithm for monitoring respiratory virus–like illness, by pathogen category and week, Massachusetts, USA, October 2015–January 2024. A) October 2015–January...
• Table 1 . Respiratory pathogens and test types included in RAVIOLI algorithm for monitoring respiratory virus–like illness
• Table 2 . ICD-10 diagnosis codes that met the positive predictive value threshold for confirmed respiratory viral illnesses and are included in the RAVIOLI algorithm for monitoring respiratory virus–like illness

Suggested citation for this article : Cocoros NM, Eberhardt K, Nguyen V-T, Brown CM, DeMaria A, Madoff LC, et al. Electronic health record–based algorithm for monitoring respiratory virus–like illness. Emerg Infect Dis. 2024 Jun [ date cited ]. https://doi.org/10.3201/eid3006.230473

DOI: 10.3201/eid3006.230473

Original Publication Date: May 13, 2024

Table of Contents – Volume 30, Number 6—June 2024

Please use the form below to submit correspondence to the authors or contact them at the following address:

Noelle M. Cocoros, Harvard Pilgrim Health Care Institute, Department of Population Medicine, 401 Park Dr, Ste 401 East, Boston, MA 02215, USA

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Ascension Cyberattack: Electronic Health Records System Not Working, Some Elective Procedures ‘Temporarily Paused’

St. Louis-based Ascension, which operates 140 hospitals in the U.S., said in its latest update that it did not have a timeline for restoring its system.

Ascension, a health system with 140 hospitals and operations in 19 states and Washington, D.C. that said it suffered a data breach this week , said Thursday that its electronic health records system was “currently unavailable” and that it was pausing some non-emergency elective procedures at its hospitals “out of an abundance of caution.”

The nonprofit and Catholic health system said that on Wednesday it detected “unusual activity on select technology network systems.” In an update on Thursday, Ascension referred to the data breach as a “cybersecurity incident” and said that it was working “around the clock with internal and external advisors to investigate, contain, and restore our systems following a thorough validation and screening process.” The nonprofit had already said that it was using Mandiant to assist in the investigation and remediation process.

The St. Louis-based health system said in its latest update that it did not have a timeline for restoring its system.

[ RELATED STORY: Analysis: Change Healthcare Attack Shows What Happens When Cybersecurity Is Ignored In M&A ]

In addition to its electronic health records system being unavailable, the health system said that its MyChart system wasn’t functional. MyChart allows patients to access their medical records and communicate with healthcare providers. Ascension said some phone systems and various systems to order certain tests, procedures and medications were also not working.

The health system was advising patients to bring appointment notes on their symptoms and a list of current medications and prescriptions numbers or prescription bottles “so their care team can call in medication needs to pharmacies.”

In addition, “Out of an abundance of caution... some non-emergent elective procedures, tests and appointments have been temporarily paused while we work to bring systems back online.”

Ascension says it has 134,000 associates, has 35,000 affiliated providers and operates 140 hospitals.

The latest cyberattack on a major healthcare system comes on the heels of other notable health sector data breaches.

In February, a cyberattack against a unit within UnitedHealth Group subsidiary Optum, Change Healthcare, led to major disruptions for U.S. pharmacies and patients, according to reports. The attack forced UnitedHealth to pay a $22 million ransom and admit that a lack of multifactor authentication on a Change Healthcare server enabled the attack to succeed.

In January 2023, Lehigh Valley Health Network in Pennsylvania was hit by a cybersecurity attack by the ransomware gang known as BlackCat. In that attack, more than 2,700 people reportedly were affected by the hack, which included the subsequent leak of nude photos and personal information of cancer patients.

Last month, the U.S. Department of Health and Human Services warned the health sector that threat actors were “employing advanced social engineering tactics to target IT help desks in the health sector and gain initial access to target organizations.” According to the alert, organizations should use Microsoft Authenticator with number matching and remove SMS as an MFA verification option, among other directives.

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Electronic health records system in operation at Spanish Town Hospital

KINGSTON, Jamaica — The Electronic Health Records (EHR) System is now operational at the Spanish Town Hospital in St Catherine, with full implementation set for the end of this month.

This would bring to three the total number of health facilities to have implemented the EHR System under the Ministry of Health and Wellness Health System Strengthening Programme (HSSP).

Speaking at a Jamaica Information Service (JIS) Think Tank on May 14, HSSP Programme Manager, Orrett Clarke, noted that the contract for the STH implementation was valued at over US$5 million and said the design and costings had been completed for eight facilities that are being upgraded under the programme.

He pointed out that the system had already been fully implemented at the May Pen Hospital and the May Pen East Health Centre.

The three facilities are part of the 13 that have been earmarked for upgrades under component one of the programme.

Clarke further explained that the HSSP has two main components.

“Component one focuses on the upgrade of infrastructure and equipping three hospitals and 10 health centres. Component two focuses on the digitalisation of our health centres and hospitals,” he said.

The programme manager pointed out that the focus areas for component one are St Catherine, Clarendon and St Ann.

“The three hospitals are Spanish Town Hospital, St Ann’s Bay Regional Hospital and May Pen Hospital. The health centres that we are focusing on in St Catherine are St Jago Park, Greater Portmore and Old Harbour.  In Clarendon, we’re focusing on May Pen East, May Pen West and Mocho Health Centres and Chapelton Community Hospital; and in St Ann, it’s Brown’s Town, Ocho Rios and St Ann’s Bay Health Centres,” Clarke explained.

The HSSP aims to increase the capacity of selected health centres and hospitals to provide comprehensive health promotion, disease prevention and treatment to meet the specific needs of individuals in the community, through tailored infrastructure upgrades to facilities, linked information systems and developing standardised levels of care.

These actions should boost the island’s capacity to address the scourge of non-communicable diseases (NCDs) and the challenge of communicable illnesses.

Clarke explained that the programme, which began with an initial investment of $50 million, through a loan agreement between the Government of Jamaica and the Inter-American Development Bank (IDB), was reassessed and found to require more funding.

“As of December 2023, the Government of Jamaica and the Inter-American Development Bank actually reformulated the loan and signed a new agreement for US$148 million. Of this amount the IDB will give us a loan of $50 million, the Government of Jamaica will be providing $87.4 million and the European Union will come on board to give us US$10 million,” he said.

The programme has also been extended from an original completion timeline of 2023 to the Financial Year 2028/2029.

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Ascension hospitals hit by cyberattack seeing widespread disruptions in patient care

Ascension hospitals in Wisconsin and across the U.S. were hit Wednesday by a cyberattack that has interfered with its computer network and led to major disruptions in patient care that have continued into Thursday.

The cyberattack has led to canceled appointments, delayed care and confusion at Ascension hospitals and health care facilities in Wisconsin and across the country.

Health care workers at Ascension Wisconsin sites report not having access to Epic, the medical records system critical for storing patients' medical information and managing their care. That interruption means doctors and nurses cannot see patients' medical histories or other patient information, cannot communicate like they used to across hospital departments and have limited ability to see patients' prior labs or test results. They are having to use paper records to track patient conditions, order procedures and write prescriptions, according to health care workers.

Some patients reportedly were unable to use MyChart, the online platform for patients to make appointments, check lab results and talk with their physician.

"This is a crisis situation," said Tracey Schwerdtfeger, a registered nurse at Ascension St. Francis Hospital on Milwaukee's south side and an official of the union that represents health care workers there. "It's really just seemed to paralyze a lot of the stuff we need to do."

It is unclear when the situation might be resolved.

Company said it is working to resolve the issue

In an email obtained by the Journal Sentinel with a message from Ascension CEO Joseph Impicciche to health care workers, he said Ascension was working "diligently to resolve the issues as quickly as possible."

"It is unclear how long it will take to get all systems back on track," Impicciche's message said.

The email also instructed health care workers to "prepare and act as if this downtime will last into the foreseeable future."

In a statement posted on its website , Ascension said it detected "unusual activity on select technology network systems" Wednesday, later determined to be a "cyber security event." It is unclear what kind of attack it was and whether ransomware was involved.

The statement says Ascension responded immediately, opened an investigation and began efforts to correct the situation. The statement alluded to ongoing interruptions to some systems as a result of the situation, but did not provide specifics.

"Our care teams are trained for these kinds of disruptions and have initiated procedures to ensure patient care delivery continues to be safe and as minimally impacted as possible," the statement said. "There has been a disruption to clinical operations, and we continue to assess the impact and duration of the disruption."

An earlier version of Ascension's statement urged its business partners to temporarily sever online connections to its system.

Disruption leads to work-arounds for patient care

The disruptions mean it will take longer for patients to get care, but health care workers are doing the best they can to take care of patients and find workarounds, said Connie Smith, president of the Wisconsin Federation of Nurses and Health Professionals, the union that represents health care workers at Ascension St. Francis Hospital.

Union members at St. Francis are worried about their ability to provide quality care if they don't have the necessary technology. Without access to the records system, some hospital units don't even know which patients are scheduled to show up for appointments, much less what their appointment is for, said Gavin Rice, an ultrasound tech at St. Francis Hospital and an officer of the union representing health care workers there.

Many patients scheduled to get a scan or other imaging at St. Francis on Wednesday were sent away or their appointments canceled, Rice said, because workers couldn't access physicians' orders in order to confirm the procedure. For patients in the emergency room, they can get imaging, but it is more cumbersome, he said.

"Imaging results are taking hours which can have a very negative impact especially if it’s something that is very serious," Schwerdtfeger said.

The shutdown of the Epic system has also negatively affected health care workers' ability to monitor patients' vital signs in the emergency department, to page doctors and to locate a physician or specialist for a consult, she said.

One physician who works at Ascension and spoke on the condition of anonymity for fear of repercussions advised patients who are critically ill or who have chronic illnesses that require detailed follow-up to avoid Ascension locations until the crisis is over.

Under this situation, when a patient comes in to an Ascension hospital or office for an appointment or a visit, doctors are "flying blind," the physician said.

"You have no backstory of the person. You don't know what the chief complaint is. You don't know the history of the patient," the physician said. "You’re completely blind."

Cyberattacks becoming increasingly common

Cyberattacks are becoming increasingly common in health care, often affecting protected health information along with other data, such as account numbers, Social Security numbers, phone numbers and addresses.

Earlier this year, Change Healthcare, part of the conglomerate UnitedHealth, was hit by a cyberattack — one of the worst hacks to hit U.S. healthcare — that caused widespread disruptions in payments to doctors and health facilities. UnitedHealth ended up paying a ransom of $22 million in cryptocurrency, its CEO told a Congressional committee earlier this month .

Ascension is working with Mandiant, a cybersecurity consulting company, to investigate its cyberattack and help determine what information, if any, was compromised in the attack.

In its statement, Ascension said it would notify any individuals affected if it found any sensitive information was compromised.

A Catholic health system headquartered in St. Louis, Missouri, Ascension has around 140 hospitals , along with other care facilities, across 18 states and the District of Columbia . The national health system reported having about 132,000 employees at the end of 2023. .

In Wisconsin, the health system has 17 hospitals in southeastern Wisconsin and the Fox Valley, in addition to many physician offices and other health care sites.

This story has been updated with a correction to the number of states in which Ascension has health care facilities. The correct number is 18.

The Detroit Free-Press and Reuters contributed to this story.