Medical Records Clerk

General Summary:

Transfers current and historical patient information from a paper chart into an electronic medical record
(EMR). Performs data entry into the EMR system using scanning. Functions performed include prepping,
scanning, quality control and indexing of medical record documents. Maintains daily workflow, ensuring that
records are processed in a timely and efficient manner and are of the highest possible quality for end user
viewing. Maintains confidentiality in all aspects of the job. Prepares medical record documents for scanning
into the electronic document imaging system following established department procedures. Examines each
page and verifies patient identification and quality of document prior to scanning. Scans all prepped
documents into the electronic document imaging system on a daily basis in order to ensure quality images are
available to end users within the timeframe established in department guidelines. Researches duplicate
medical records and corrects the record according to guidelines. Answers department telephones in a timely
and courteous manner, providing good customer service.

Principal Duties and Responsibilities:

1. According to established procedures, organizes and maintains medical records in electronic format.

2. Receives requests for patients' charts from physicians and Clinic support departments, obtains charts,

prepares, scans, and indexes the chart to be used in electronic format, if not already in that format.
Pulls and prepares charts for scheduled appointments according to established procedures.
Communicates chart status with requesting party according to established guidelines.

3. Assures integrity and quality of medical records stored in the electronic medical records (EMR)

through document preparation, scanning, indexing and quality control procedures.

4. Receives patient-related information such as laboratory reports, operation reports, discharge

summaries, dictation and so forth to be included in patient charts, and sorts and arranges in order to
be scanned into the electronic medical record.

5. Maintains patient/physician confidentiality in all situations.

6. Actively participates in the Clinic’s process improvement program. Seeks to identify and resolve issues

through teamwork and collaboration

7. Assists in training of new medical records staff as assigned.

Knowledge, Skills and Abilities Required:

1. Ability to read and write in order to review medical records for completeness, and basic knowledge of

medical terminology as normally acquired through completion of high school.

2. Approximately one to three months on the job experience necessary in order to learn medical

terminology, electronic medical record systems, and to learn Clinic policies and procedures.

CLINIC Page 2
Job Description
Medical Records Clerk

3. Interpersonal skills necessary in order to effectively interact with patients, physicians and other Clinic

personnel when obtaining and supplying factual medical record information.

4. Basic analytical skills necessary in order to identify missing and/or incorrect information from patient

charts and to contact appropriate sources to complete records.

5. Ability to work in a team setting and in close cooperation with others in an office setting.

6. Strong skills & ability with computer systems, scanners, facsimile devices.

7. Ability to work independently and show a preference for routine, detailed and organized work.

8. Ability to concentrate and pay close attention to detail for one-hundred percent of work time when

preparing, scanning, and indexing medical records.

9. Ability to maintain confidentiality in all aspects of the job.