HealthcareISCO 3252
Medical records clerk
A medical records clerk is a person who organises, updates and stores patient records and makes them available to clinical staff.
Check yourself in a minute: medical records clerk
Rate 5 of the 27 essential skills of this occupation (European ESCO data). No account needed.
deliver case notes
display medical problems
manage healthcare users' data
maintain healthcare user data confidentiality
collect healthcare user's general data
About medical records clerk
The medical records clerk manages medical records: opening and completing files, locating a patient's records for an appointment or a consultation, and releasing them to people entitled to see them. Information is transferred from paper records into electronic form, data is processed and entries put in order.
The clerk carries out clinical coding procedures, assigning codes from the classifications in force to diagnoses and procedures, on which reporting and payment for an episode of care depend. Medical informatics and hospital systems are used, and case documentation is supplied when it is required in proceedings, in a disability assessment or in an audit.
Medical records clerk skills include keeping healthcare user data confidential, checking the legal basis for every disclosure, and refusing information over the telephone to anyone whose identity cannot be confirmed. The quality standards of medical practice are observed throughout. Formal requirements are set by the employer.
Key Work Functions
Core areas of responsibility for a medical records clerk.
1
Electronic Health Record Management
- Transfer patient information from paper records to electronic health record systems with accuracy and consistency
- Verify data accuracy and completeness before filing information in the system
- Maintain proper database organization and ensure all records are properly indexed and searchable
- Retrieve and deliver case notes to medical staff upon request in accordance with access protocols
2
Data Privacy and Compliance
- Maintain healthcare user data confidentiality and comply with RODO and healthcare legislation requirements
- Follow organizational guidelines and quality standards related to healthcare practice
- Document and report any data breaches or compliance violations according to protocol
3
Records Organization and Storage
- Archive healthcare users' records in both physical and digital formats using proper storage and filing systems
- Identify and categorize patients' medical records by diagnosis, type, and date
- Manage data storage systems and ensure secure handling of sensitive information
4
Clinical Coding and Documentation
- Apply clinical coding standards to medical documents and identify medical problems in patient records
- Collect and organize patients' general data including demographics, medical history, and contact information
- Ensure complete and accurate documentation according to healthcare terminology and standards
Do You Have the Skills for This Role?
Core competency requirements inferred from the occupation's skill profile. Take the free assessment to see how you match.
Must-Have Skills (Advanced)
Problem SolvingAdvanced
Decision MakingAdvanced
CommunicationAdvanced
Supporting Skills
CollaborationIntermediate
Learning AgilityIntermediate
European Skills Framework
Skills and knowledge areas required for this occupation based on European classification.
Essential (27)
health care legislationhealth care legislationThe patients` rights and responsibilities of health practitioners and the possible repercussions and prosecutions in relation to medical treatment negligence or malpractice.medical terminologymedical terminologyThe meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.databasedatabaseThe classification of databases, that includes their purpose, characteristics, terminology, models and use such as XML databases, document-oriented databases and full text databases.administrative tasks in a medical environmentadministrative tasks in a medical environmentThe medical administrative tasks such as registration of patients, appointment systems, record keeping of patients information and repeated precribing.health records managementhealth records managementThe procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of rec...health care systemhealth care systemThe structure and function of health care services.data storagedata storageThe physical and technical concepts of how digital data storage is organised in specific schemes both locally, such as hard-drives and random-access memories (RAM) and remotely, via network, internet ...medical informaticsmedical informaticsThe processes and tools used for the analysis and dissemination of medical data through computerized systems.clinical codingclinical codingThe matching of clinical statements with standard codes of illnesses and treatments through use of a classification system.document managementdocument managementThe methodology of tracking, managing and storing documents in a systematic and organised manner as well as keeping a record of the versions created and modified by specific users (history tracking).deliver case notesdeliver case notesDeliver the appropriate case notes in a timely manner to those requesting them.display medical problemsdisplay medical problemsEmphasize significant medical issues in a way that the attention of any healthcare professional using the record is directed on them.archive healthcare users' recordsarchive healthcare users' recordsProperly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.manage healthcare users' datamanage healthcare users' dataKeep accurate client records which also satisfy legal and professional standards and ethical obligations in order to facilitate client management, ensuring that all clients' data (including verbal, wr...maintain healthcare user data confidentialitymaintain healthcare user data confidentialityComply with and maintain the confidentiality of healthcare users` illness and treatment information.use electronic health records management systemuse electronic health records management systemBe able to use specific software for the management of health care records, following appropriate codes of practice.collect healthcare user's general datacollect healthcare user's general dataCollect qualitative and quantitative data related to the healthcare user's anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests p...comply with quality standards related to healthcare practicecomply with quality standards related to healthcare practiceApply quality standards related to risk management, safety procedures, patients feedback, screening and medical devices in daily practice, as they are recognized by the national professional associati...identify patients' medical recordsidentify patients' medical recordsLocate, retrieve and present medical records, as requested by authorized medical personnel.adhere to organisational guidelinesadhere to organisational guidelinesAdhere to organisational or department specific standards and guidelines. Understand the motives of the organisation and the common agreements and act accordingly.collect statistics on medical recordscollect statistics on medical recordsPerform statistical analysis of various medical records of the healthcare facility, referring to the number of hospital admissions, discharges or waiting lists.perform backupsperform backupsImplement backup procedures to backup data and systems to ensure permanent and reliable system operation. Execute data backups in order to secure information by copying and archiving to ensure integri...type on electronic devicestype on electronic devicesType fast and flawless on electronic devices such as computers in order to ensure a quick and accurate data entry.apply organisational techniquesapply organisational techniquesEmploy a set of organisational techniques and procedures which facilitate the achievement of the set goals set such as detailed planning of personnel's schedules. Use these resources efficiently and s...work in multidisciplinary health teamswork in multidisciplinary health teamsParticipate in the delivery of multidisciplinary health care, and understand the rules and competences of other healthcare related professions.perform clinical coding proceduresperform clinical coding proceduresMatch and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.process dataprocess dataEnter information into a data storage and data retrieval system via processes such as scanning, manual keying or electronic data transfer in order to process large amounts of data.
Optional (15) — show
medical studiesmedical studiesThe basics and terminology of medical studies.pharmacologypharmacologyPharmacology is a medical specialty mentioned in the EU Directive 2005/36/EC.communicate with customerscommunicate with customersRespond to and communicate with customers in the most efficient and appropriate manner to enable them to access the desired products or services, or any other help they may require.answer patients' questionsanswer patients' questionsRespond in a friendly and professional manner to all inquiries from current or potential patients, and their families, of a healthcare establishment.use databasesuse databasesUse software tools for managing and organising data in a structured environment which consists of attributes, tables and relationships in order to query and modify the stored data.communicate in healthcarecommunicate in healthcareCommunicate effectively with patients, families and other caregivers, health care professionals, and community partners.use communication techniquesuse communication techniquesApply techniques of communication which allow interlocutors to better understand each other and communicate accurately in the transmission of messages.send samples to laboratorysend samples to laboratoryForward collected samples to the concerned laboratory, following strict procedures related to the labeling and tracking of the information on the samples.work in a multicultural environment in health carework in a multicultural environment in health careInteract, relate and communicate with individuals from a variety of different cultures, when working in a healthcare environment.manage digital documentsmanage digital documentsManage various data formats and files by naming, publishing, transforming and sharing files and documents and transforming file formats.communicate in foreign languages with health service providerscommunicate in foreign languages with health service providersApply foreign languages in communicating with health service providers such as doctors and nurses.review patient's medical datareview patient's medical dataAssess and review relevant medical data of patients such as X-rays, medical history and laboratory reports.transfer medical informationtransfer medical informationExtract information from a patient's notes and enter them in a computer programme.participate in medical records' auditing activitiesparticipate in medical records' auditing activitiesAssist and help with any requests arisen during audits related to the archiving, filling and processing of medical records.customer servicecustomer serviceProcesses and principles related to the customer, client, service user and to personal services; these may include procedures to evaluate customer's or service user's satisfaction.
Related Occupations
Occupations that need many of the same essential skills, so the move between them is shortest.
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Frequently asked questions
What does a medical records clerk do?
Medical records clerks organise, keep up-to-date and archive patients` records for medical staff availability. They transfer medical information from a patient’s paper records to an electronic template.
What skills does a medical records clerk need?
A medical records clerk needs 27 essential skills, including health care legislation, medical terminology, database, administrative tasks in a medical environment, health records management.
Will AI replace medical records clerk jobs?
The AI disruption score for medical records clerk is 85/100 (very high risk). Skills most exposed to automation: type on electronic devices, medical terminology, perform backups. Most resilient: work in a multicultural environment in health care, work in multidisciplinary health teams, communicate in healthcare.
AI Replacement Risk
85/ 100
Very High Risk
Low riskHigh risk
Skills most at risk from AI
Skills resilient to automation
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