Key Responsibilities and Required Skills for a Health Records Clerk

🎯 Role Definition

The Health Records Clerk serves as the custodian of patient health information, a critical role that underpins the quality of patient care, ensures regulatory compliance, and supports the operational efficiency of a healthcare facility. This position is responsible for the complete lifecycle of a medical record, from creation and maintenance to secure storage and appropriate release. Working at the intersection of administration and patient care, the clerk ensures that accurate, complete, and confidential patient data is readily available to authorized clinical and administrative staff, directly impacting patient safety and treatment outcomes. This role requires a meticulous and principled individual who understands the sensitive nature of health information and is committed to upholding the highest standards of privacy and accuracy.

📈 Career Progression

Typical Career Path

Entry Point From:

Medical Receptionist or Patient Services Representative
Administrative Assistant (in a healthcare setting)
Recent graduate from a Health Information or Medical Office Administration program

Advancement To:

Registered Health Information Technician (RHIT)
Medical Records Supervisor or Team Lead
Health Information Analyst or Compliance Specialist

Lateral Moves:

Medical Coder or Biller
Patient Registration or Admitting Clerk

Core Responsibilities

Primary Functions

Meticulously compile, process, and maintain patient medical records in both electronic (EHR) and paper formats, ensuring all information is accurate, complete, and filed in the correct order.
Respond to and process a high volume of requests for patient health information from patients, physicians, legal entities, and insurance companies, strictly adhering to HIPAA and facility-specific release of information (ROI) policies.
Perform detailed quality assurance checks on patient charts, auditing for missing documents, incorrect filing, and unsigned orders to ensure records meet regulatory and internal standards.
Skillfully scan, index, and upload a variety of clinical documents, such as lab results, physician notes, and imaging reports, into the Electronic Health Record (EHR) system with a high degree of accuracy.
Retrieve and deliver patient charts and specific medical information to various clinical departments and physicians in a timely manner to support patient appointments, procedures, and ongoing care.
Assemble new patient charts and disassemble discharged patient charts, organizing all paperwork according to a standardized chart order before scanning or archiving.
Safeguard patient confidentiality at all times by handling all medical records with discretion and ensuring that access is restricted to authorized individuals.
Manage the intake, logging, and distribution of incoming medical records and correspondence received via mail, fax, and secure electronic portals.
Identify and merge duplicate patient medical record numbers within the master patient index (MPI) to ensure a single, comprehensive record for each patient.
Diligently file loose reports and documentation into the appropriate patient charts, ensuring the chronological and sectional integrity of the record is maintained.
Operate and maintain various office and scanning equipment, including high-speed scanners, fax machines, and copiers, troubleshooting minor issues as they arise.
Communicate professionally and effectively with clinical staff, administrative teams, and patients to clarify information, answer inquiries, and resolve issues related to medical records.
Systematically purge and prepare inactive medical records for off-site storage or destruction based on established state and federal retention schedules.
Assist in the preparation of charts for internal and external audits, including those conducted by The Joint Commission, CMS, and other regulatory bodies.
Maintain detailed logs and tracking systems, both manual and electronic, to monitor the movement and status of medical records and information requests.
Provide support for the transition from paper-based records to fully electronic systems, including back-scanning and data validation projects.
Process and document amendments to patient records as directed by healthcare providers, ensuring the changes are made in compliance with legal and facility guidelines.
Answer multi-line phone systems, screen and direct calls, and provide clear information to callers regarding medical records procedures.

Secondary Functions

Provide cross-coverage for other administrative roles, such as reception or patient registration, during periods of high volume or staff absence.
Assist in training new team members on departmental procedures, software systems, and compliance standards.
Contribute to departmental quality improvement initiatives by identifying process inefficiencies and suggesting potential solutions.
Participate in ongoing professional development and training sessions to stay current with changes in healthcare regulations, privacy laws, and technology.

Required Skills & Competencies

Hard Skills (Technical)

EHR/EMR Proficiency: Hands-on experience with Electronic Health Record systems such as Epic, Cerner, Meditech, or AthenaHealth.
Medical Terminology: A strong working knowledge of medical terms, anatomy, and clinical procedures to accurately interpret and file documentation.
HIPAA and Privacy Regulations: In-depth understanding of the Health Insurance Portability and Accountability Act (HIPAA) and other patient privacy laws.
Data Entry and Typing: High speed and accuracy in typing and 10-key data entry, often measured in Keystrokes Per Hour (KPH).
Release of Information (ROI): Knowledge of the specific legal requirements and workflows for processing requests for protected health information.
Office and Scanning Technology: Competency in operating standard office equipment, particularly high-volume scanners, fax machines, and multi-line phone systems.
Microsoft Office Suite: Proficiency in using Microsoft Outlook, Word, and Excel for communication, documentation, and basic data organization.

Soft Skills

Attention to Detail: An exceptional ability to notice and correct errors, ensuring the absolute accuracy of patient records.
Organization and Time Management: The skill to manage multiple competing priorities, track numerous requests, and meet deadlines in a fast-paced environment.
Integrity and Discretion: A strong ethical compass and the ability to handle highly sensitive and confidential information with the utmost professionalism.
Communication Skills: Clear and concise verbal and written communication abilities for interacting with a diverse range of individuals, from physicians to patients.
Problem-Solving: The capacity to identify issues, such as a missing file or a non-compliant request, and find an effective and compliant solution.
Dependability and Reliability: A consistent and trustworthy work ethic, with the ability to work independently with minimal supervision.

Education & Experience

Educational Background

Minimum Education:

High School Diploma or equivalent (GED).

Preferred Education:

Certificate in Medical Office Administration or a related field.
Associate's degree in Health Information Technology (HIT) or Health Information Management (HIM).

Relevant Fields of Study:

Health Information Management
Medical Office Administration

Experience Requirements

Typical Experience Range:
0-2 years of experience in an administrative role, preferably within a healthcare or clinical environment.

Preferred:
1+ years of direct experience working in a hospital or clinic's medical records/health information department, with proven experience handling EHR systems and processing information requests.