State of Maryland

A Health Records Technician I is the intermediate level of work compiling and maintaining health records in a State facility or local health department.  Employees in this classification do not supervise other positions.

Employees in this classification receive moderate supervision from a Health Record Technician Supervisor or Health Records Program Supervisor.

Positions in this classification are evaluated by using the classification job evaluation methodology.  The use of this method involves comparing the assigned duties and responsibilities of a position to the job criteria found in the Nature of Work and Examples of Work sections of the class specification.

The Health Records Technician Trainee, Health Records Technician I and Health Records Technician II are differentiated on the basis of the degree of supervisory control exercised by the supervisor over these employees.  The Health Records Technician Trainee learns to perform duties under close supervision.  The Health Records Technician I performs duties under close supervision at times and under general supervision at other times depending on the complexity of the specific duty being performed.  The Health Records Technician II performs the full range of duties and responsibilities under general supervision.

Maintains a system of medical records and files for a State facility concerning patients’ diagnoses, treatments, admissions, discharges and daily patient census changes;

Assembles, classifies and indexes medical data in accordance with established procedures;

Prepares statistical reports;

Codes diseases, operations, and treatments according to the established nomenclature of diagnostic conditions;

Responds to inquiries regarding information in patient records;

Maintains the confidentiality of health records in accordance with prescribed procedures;

Maintains procedural manuals;

Analyzes residents' discharge records and prepares abstracts of case histories;

Enters information into medical records and forms;

May transcribe information and enter into medical records from a digital voice recorder;

May be required to testify in court and in hearings regarding information in health records;

May give general advice and guidance to personnel throughout the facility who work with patients' records;

Performs other related duties.

Knowledge of standard English and grammar;

Knowledge of procedures and techniques necessary for the maintenance of health records;

Knowledge of medical and general clinical terminology;

Knowledge of relevant federal, State and local regulations governing medical records;

Knowledge about diseases and their effects and treatment;

Knowledge of hospital administration and organization;

Knowledge of the standard treatments and tests to be administered for specific diseases;

Skill in typing accurately at a minimum of twenty net words per minute;

Ability to code and index medical information according to recognized procedures;

Ability to prepare and compile medical reports and statistics;

Ability to perform basic mathematics;

Ability to establish and maintain effective relationships with staff members and the public and to advise them of medical record matters;

Ability to communicate effectively with employees, co-workers and the general public.

Education:   Graduation from an accredited high school or possession of a high school equivalency certificate.

Experience: One year of experience compiling and maintaining health records.

Notes:

1. Candidates may substitute additional experience on a year-for-year basis for the required education.

2. Candidates may substitute U.S. Armed Forces military service experience as a non-commissioned officer in Medical Record classifications or Patient Administration Specialists and Health Services Management specialty codes in the health records management field of work on a year-for-year basis for the required experience.

Class specifications are broad descriptions covering groups of positions used by various State departments and agencies. Position descriptions maintained by the using department or agency specifically address the essential functions of each position.

This is a Skilled Service classification in the State Personnel Management System.  All positions in this classification are Skilled Service positions.  Some positions in Skilled Service classifications may be designated Special Appointment in accordance with the State Personnel and Pensions Article, Section 6-405, Annotated Code of Maryland.

This classification is assigned to Bargaining Unit D- Health and Human Service Non-Professional classes.  As provided by State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, supervisory, managerial and confidential employees are excluded from collective bargaining.  Additionally, certain executive branch agencies are exempt from collective bargaining and all positions in those agencies are excluded from collective bargaining.

Employees in this classification are eligible to receive overtime compensation.  An employee who works more than the normal workweek is entitled to be compensated for that overtime as provided by State Personnel and Pensions Article, Section 8-305.

This classification is one level in a Non-Competitive Promotion (NCP) series.  NCP promotions are promotions by which employees may advance in grade and class level from trainee to full performance levels in a classification series.  In order to be non-competitively promoted to the next level in a NCP series an employee must: 1)  perform the main purpose of the class as defined in the Nature of Work section of the class specification; 2)  receive the type of supervision defined in the class specification, and 3) meet the minimum qualifications of the classification.