Medical Records Technician Series, GS-0675

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United States

Office of Personnel Management

Medical Records

Technician Series

GS-0675

Nov 1991, TS-110

Workforce Compensation and Performance Service

Office of Performance and Compensation System Design

Classification Programs Division

July 1999, HRCD-7

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Medical Records Technician Series

GS-0675

CONTENTS

SERIES DEFINITION .......................................................1

EXCLUSIONS .............................................................1

OCCUPATIONAL INFORMATION ............................................2

TITLES ...................................................................5

EVALUATING POSITIONS ..................................................6

GRADE CONVERSION TABLE ...............................................6

FACTOR LEVEL DESCRIPTIONS .............................................7

FACTOR 1, KNOWLEDGE REQUIRED BY THE POSITION .....................7

FACTOR 2, SUPERVISORY CONTROLS ....................................9

FACTOR 3, GUIDELINES ................................................10

FACTOR 4, COMPLEXITY ...............................................11

FACTOR 5, SCOPE AND EFFECT .........................................12

FACTOR 6, PERSONAL CONTACTS

AND FACTOR 7, PURPOSE OF CONTACTS ..............................13

FACTOR 8, PHYSICAL DEMANDS ........................................14

FACTOR 9, WORK ENVIRONMENT .......................................14

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SERIES DEFINITION

This occupation includes positions involving technical work concerned with processing and

maintaining medical records for compliance with regulatory requirements. Included in this series

are positions that review, analyze, code, abstract, and compile or extract medical records data.

The work requires a practical knowledge of medical records procedures and references and the

organization and consistency of medical records. Positions also require a basic knowledge of

human anatomy, physiology, and medical terminology.

This standard replaces the Position Classification Standard for Medical Record Technician Series,

GS-675, issued in June 1971 (TS-6).

EXCLUSIONS

1. Classify positions that primarily involve application of statistical methods, procedures, and

techniques to the collection, processing, compilation, computation, analysis, editing, and

presentation of statistical data to the Statistical Assistant Series, GS-1531.

2. Classify positions the duties of which are primarily to compose or review correspondence for

the purpose of obtaining or supplying factual information when the work

requires skill in the composition of letters and memoranda to the Correspondence Clerk

Series, GS-0309.

3. Classify positions the duties of which are primarily to perform clerical work in support of the

care and treatment given to patients in a ward, in a clinic, or other such unit of a medical

facility to the Medical Clerk Series, GS-0679.

4. Classify positions the duties of which are primarily to advise on, administer, supervise, or

perform work involving the application of accepted theories and techniques of medical records

science in the development, maintenance, analysis, and use of diagnostic and therapeutic

medical records to the Medical Records Administration Series, GS-0669.

5. Classify positions that primarily involve operating or supervising the operation of keyboard

controlled machines to transcribe data or verify data in a form that can be used in automated

data processing systems to the Data Transcriber Series, GS-0356.

6. Classify positions that primarily involve supervising, verifying, or performing work coding

information from schedules, questionnaires, reports, documents, and other written source

material, according to codes involving numerical or alphabetical symbols to the Coding Series,

GS-0357.

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OCCUPATIONAL INFORMATION

Health care facilities maintain a permanent medical record that contains health care

information to support the diagnosis and justify treatment rendered on each patient. This record

includes the patient's medical history, physical examination results, X-ray and laboratory reports,

diagnosis and treatment plans, and orders and notes from doctors, nurses, and other health care

professionals. Accurate medical records are essential for clinical, legal, and fiscal purposes, for

correct and prompt diagnosis and treatment of illnesses and injuries, and for continuity of care.

Medical records also serve as a source of information for other uses. They provide background

and documentation for insurance claims, legal actions, professional review of prescribed

treatments and medications, and training of health professionals. Medical records provide useful

information for research and resource management planning purposes. They contain data for

clinical studies, evaluation of costs of various medical procedures, and assessment of health needs,

and justify the management costs associated with treatment.

Medical records clerks and technicians assemble, analyze, code, abstract, report, and maintain

medical records information in manual and automated records systems. They organize and check

medical records for completeness, accuracy, and compliance with regulatory requirements. When

assembling a patient's medical record, they first ensure the medical record is complete. With a

paper medical record, this means that all documentation is present in appropriate format and

sequence, identified, and signed. Employees assure that all documents reach the record before

coding is done. In a growing number of medical centers, the medical staff use computers rather

than the traditional paper record to note patient care information. In these hospitals, technicians

use their own computer terminals to retrieve information from the patient's record in the hospital's

central computer. A few medical centers are developing larger patient care information systems

using optical disks and satellite transmission of data from one facility to another.

Coding

Employees must apply a thorough knowledge of various medical and clinical processes such

as disease, illness, or injury and conditions (e.g., pregnancy, psychological) and their

interrelationships to code the record correctly. They abstract all the necessary information and

assign codes which most accurately describe each documented diagnosis, surgical procedure, and

special therapy or procedure according to established guidelines and practices. Where multiple

diagnoses and procedures are listed, they must relate each surgical procedure to the proper

diagnosis. They select and assign a principal code along with other appropriate codes.

Technicians must assure that the diagnosis responsible for the length of stay is appropriately

identified and that the secondary diagnoses are sequenced properly in order to assure maximum

allocation under the Diagnostic Related Groups (DRG's) System. Because information in the

medical record is the basis for reimbursement as well as clinical decision making, coding entries

must be complete and accurate. A coding error can mean a financial loss for the hospital because

the amount of reimbursement depends on the correct coding of diagnoses and procedures to

ensure the appropriate DRG's assignment.

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Quality Control and Utilization Review

As part of quality control or utilization review, technicians compile, abstract, and analyze data

from medical records. For example, they develop information to find trends which show

differences in the average length of a hospital stay according to diagnosis, attending physician,

procedures performed, and health care provided. They also retrieve, analyze, and present

information for the institution's quality assurance studies and patient care evaluation activities.

Registries

Technicians serve as registrars maintaining special registries. These registries show

occurrences of disease by type, such as cancer, injury, or stroke, extent of illness, and survival.

Technicians maintain health record indexes and compile administrative and health statistics for

public health officials, medical center management, planners, and others.

Correspondence

In response to inquiries from patients, their authorized representative, and other third parties,

such as law firms and insurance companies, government agencies and researchers, medical records

technicians determine the validity of each request and provide medico-legal information from

medical records. They determine eligibility for release of information, abstract information from

the medical record, obtain supplemental reports, write factual summaries, and complete forms for

services. Technicians follow established procedures to ensure the confidentiality of health

information.

Research and Special Projects

Technicians perform data retrieval for medical center management and clinical staff for

research, diagnostic, and teaching purposes. Working with the researcher, they determine what

information is needed for a particular project and how to compile it.

The day-to-day tasks of medical records technicians vary with the complexity and

characteristics of the facility. Affiliated treatment facilities house many critically ill patients and

use the latest treatment methods resulting in comprehensive medical records with many diagnoses

and treatments. The time and knowledge needed to analyze and code a record increases in

proportion to the patient's length of stay and the complexity of the patient's diagnosis and

treatment. The scope of the work performed by the medical records technician is increased when

there are many health care providers involved in the care of a single patient. Several physicians

may provide care to one patient, all of whom write progress notes and determine diagnoses and

treatments. Medical records technicians in facilities offering a greater number of specialties,

health care providers, and diagnostic and therapeutic services must have increased knowledge and

understanding of many health care processes. They must stay abreast of new procedures and

therapies so they can analyze and code the record.

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In most facilities, medical records administrators manage medical records activities, but in

some facilities an experienced medical records technician may head the department. In other

medical records departments, a technician is usually responsible for supervising and training

medical records clerks. Also, in some medical facilities, technicians specialize in a certain area.

For example, a medical records technician may analyze the record to be sure that all correct

documents are in the record and ready to code. Another technician then codes the record. In

some cases, the technician is responsible for only those records needed for legal issues and

correspondence. In facilities that employ fewer people, a medical records technician may be

responsible for everything from analysis and coding to providing help on legal issues.

Knowledge Required

Medical records technicians must have a knowledge of:

-- Medical terminology and usages, covering the full range of general medical, surgical,

pharmaceutical, hospital terms, medical abstracts, and abbreviations.

-- Physiology, major anatomical systems, and related disease processes.

-- Medical records forms and formats.

-- Correlation of laboratory test results, procedures, and treatments with diagnosis.

-- Medical records classification systems and references such as the International Classification

of Diseases (ICD), Diagnostic Related Groups (DRG's), Physician's Desk Reference (PDR),

Current Procedural Terminology (CPT), medical dictionaries, manuals, textbooks, and

glossaries.

-- Legal and regulatory requirements of medical records to be sure the record is acceptable as a

legal document.

-- Laws and regulations on the confidentiality of medical records (Privacy Act and Freedom of

Information Act) and the procedures for informed consent for release of information from the

record.

-- Computerized data entry and information processing systems.

-- Data collection methods for basic health care and research information.

Technician Versus Administrator Positions

Medical records administrators use broad medical records management knowledges, concepts,

and principles in the administrative management of medical records systems, programs, or

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specialty areas. Medical records technicians work in support of the specialist to achieve program

goals.

Both medical records administrators and medical records technicians review and analyze

records. The administrator performs analyses that go beyond the contents of individual patient

records to assess the effectiveness of the medical records program. The administrator analyzes

the medical data requirements of the program and develops effective methods to collect and use

this information on an institution-wide basis. The technician analyzes individual records for

completeness, use of accepted terminology, and for compliance with regulatory requirements.

Medical records administrators are responsible for planning and developing the patient

information system, including developing operating methods and procedures covering all medical

records functions which require an understanding of the interrelationship of record services with

the rest of the facility's services. They must also apply administrative and management theories,

principles, and techniques to many situations and programs.

Medical records technicians follow established methods and procedures which have been

developed by medical records administrators. They are primarily concerned with the application

of these guidelines to specific medical records operations. Medical records technicians are

proficient in a number of medical records functions such as analyzing records, coding information,

and abstracting information from records to answer correspondence.

TITLES

Medical Records Clerk is the title for nonsupervisory positions in grades GS-3 and GS-4.

Medical Records Technician is the title for nonsupervisory positions in grades GS-5 and

above.

Supervisory Medical Records Technician is the title for supervisory positions which meet the

criteria in the appropriate supervisory guide.

Lead Medical Records Technician is the title for positions which meet the criteria in the Work

Leader Evaluation Guide.

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EVALUATING POSITIONS

Evaluate positions using factor level descriptions and assigned point values in this standard.

For those few positions that may warrant factor levels above and below the levels provided in this

standard, refer to the FES Primary Standard or other related standards.

Evaluate positions which perform supervisory and program management work with the

criteria in this standard and the appropriate supervisory guide. When this approach produces two

different results, the proper grade is the higher of the two.

Evaluate work leader positions using the Work Leader Grade Evaluation Guide.

GRADE CONVERSION TABLE

Total points on all evaluation factors are converted to GS grade as follows:

GS Grade Point Range

455-650

655-850

855-1100

1105-1350

1355-1600

1605-1850

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FACTOR LEVEL DESCRIPTIONS

FACTOR 1, KNOWLEDGE REQUIRED BY THE POSITION

Level 1-3 -- 350 Points

Knowledge of standardized medical records procedures, methods, and requirements to

perform a full range of routine medical records clerical assignments. Employees use a general

knowledge of the procedures, rules, operations, sequence of steps, documentation requirements,

time requirements, functions, and workflow to process medical records, to review records for

accuracy and completeness, and to keep track of processing deadlines. Employees use an

elementary understanding of human anatomy and physiology and a knowledge of medical

terminology to code records. This level requires basic knowledge of regulations on the

confidentiality of medical records.

Illustrations:

- Employees assemble medical records in proper sequence ensuring all necessary forms and

documents are present, accurate, and complete. They perform coding of diseases, surgical

procedures, and causes of injury using standard medical records references, i.e., DRG's.

- Employees compose responses to routine requests for release of patient information. They

select and compile information from medical records and prepare correspondence to insurance

companies and physicians concerning information from the medical record.

- Employees assemble and issue data collected by the tumor registry. They answer requests for

data and prepare routine and special reports which summarize cancer patient treatment

records. They collect core data from patients records, including demographic characteristics,

diagnostic procedures, diagnoses, stage and extent of disease, and treatment, as documented

by medical staff members. They code stage of disease using the International Classification of

Diseases for Oncology and carry out follow-up programs to gather information about the

quality and length of survival.

Level 1-4 -- 550 Points

In addition to the knowledges and skills at Level 1-3, positions require a practical knowledge

of well-established medical records procedures, regulations, and principles to carry out a variety

of medical records functions such as analysis, coding, quality assurance, and compiling data. In

addition, employees use--

-- elementary practical knowledge of the structure and physiology of major anatomical systems

and the major disease processes of each;

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-- knowledge of a broad range of medical records references and regulatory requirements for

medical records;

-- knowledge of classification systems to code diagnostic and operative/procedural information

using various classification methods; and

-- skill to collect and organize data for statistical reports.

Illustrations:

- Employees analyze the consistency of records that include references to several diseases, and

various medical, diagnostic, therapeutic, and surgical procedures. They identify

inconsistencies or discrepancies among medical documentation and discuss with appropriate

staff member. They code medical records by determining and sequencing codes to reflect the

resources used in the care of patients. They relate an operation to the proper diagnosis when

there are multiple diagnoses and select the most descriptive code when more than one

anatomical location is involved.

- Employees prepare correspondence and summaries of medical records in response to a variety

of requests. They review and screen requests to release medical information from records by

interpreting and applying the Privacy Act and corresponding local policies governing the

release of medical information or health records to individuals other than the patient.

- Employees assist in the technical evaluation of medical records for compliance with regulatory

requirements. They review patient medical records to gather information on the reasons for

admission and length of stay using special screening criteria. They refer utilization data to

quality assurance specialists for review and resolution and identify and code the stage and

extent of disease by using the ICD.

Level 1-5 -- 750 Points

Employees apply knowledge and skill as described in Level 1-4 and in addition, a thorough

knowledge of medical records activities, operations, and regulations to carry out limited

specialized assignments such as setting up special registries. Technicians aid in a wide range of

quality assurance studies, code complicated medical records, or make recommendations to

improve procedures for compiling and retrieving medical record information. Technicians apply

an extensive knowledge of regulatory requirements governing medical record operations to

provide problem-solving services in specific medical record functions and in research activities.

Illustrations:

- Employees assist in the performance of a variety of quality assurance studies. They --

-- review a specific area of a medical record department as part of a quality assurance team;

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-- identify problems and potential problems in record documentation; and

-- provide evidence that various functions within the section are in compliance with

requirements of regulatory agencies.

- Employees perform a wide range of technical duties involved in the development and analysis

of diagnostic and therapeutic cancer data. They coordinate activities for a facility's tumor

registry by --

-- setting up procedures within the framework established by higher level authority;

-- devising administrative procedures or processes to use in identifying diagnosed cases of

malignant disease through audits of medical record disease indices;

-- organizing and maintaining a data system which conforms to the standards of tumor

registry operations and meets the needs of the users of the registry data; and

-- maintaining quality control of case-finding, abstracting, coding, and follow-up procedures.

- Employees code complicated medical records having diagnostic, surgical, and therapeutic

procedures on specific DRG's that are identified as difficult to classify. They also use

specialized procedures and methods to correct and amend records.

- Employees assist clinical services staff in retrieving data for research, diagnostic, and teaching

purposes. They advise researchers of the data available and retrieve and compile specified

reports. They aid staff in research activities by offering guidance on the best approach to

gather data, and they compile requested data for special studies and research projects that

directly relate to the problem.

FACTOR 2, SUPERVISORY CONTROLS

Level 2-1 -- 25 Points

The supervisor or higher grade technician makes assignments and gives specific and detailed

instructions about tasks. The supervisor is readily available to provide additional guidance.

The employee performs the work as instructed, referring to the supervisor all problems not

specifically covered by instruction.

The supervisor maintains close control over the work by checking it in progress and reviewing

completed work for accuracy, adequacy, and adherence to instructions.

Level 2-2 -- 125 Points

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The supervisor provides continuing assignments showing generally what is to be done,

limitations, quality and quantity expected, deadlines, and priority of assignments. The supervisor

provides additional, specific instructions for new or difficult assignments including work methods

or advice on source materials available.

The employee carries out recurring assignments and refers deviations from established

procedures, unanticipated problems, or unfamiliar situations not covered by instructions to the

supervisor for a decision. The employee uses initiative in choosing the best method for carrying

out the work according to instructions, policies, or previous cases.

The supervisor assures that finished work and methods used are technically accurate and in

compliance with instructions or established procedures.

Level 2-3 -- 275 Points

The supervisor makes assignments by defining the overall goals and priorities of the work and

helps the technician with unusual situations which do not have clear precedents.

At this level, the technician plans and carries out assignments, and handles problems and

deviations in the work assignment using established policies, instructions, and accepted practices

in medical records management. The supervisor places considerable reliance upon the technician's

knowledge of medical records.

The supervisor reviews the work for results achieved, technical soundness, and conformity to

medical record policy and requirements.

FACTOR 3, GUIDELINES

Level 3-1 -- 25 Points

Specific and detailed guidelines and procedures such as procedural manuals, coding

references, operating guides, verbal instructions, and medical dictionaries cover the assignments.

The employee works in strict adherence to the guidelines referring deviations to the supervisor

for direction.

Level 3-2 -- 125 Points

There are well-established procedures for doing the work and other specific guidelines are

available including a variety of written medical record references and regulatory requirements.

The number and similarity of guidelines and work situations require the employee to use

judgment to identify and select the most appropriate guidelines, references, and procedures for

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application in making minor deviations to adapt the guidelines to specific cases. Employee refers

situations to which existing guidelines are not applicable to the supervisor.

Level 3-3 -- 275 Points

Guidelines are a variety of technical instructions, technical manuals, hospital regulations,

regulatory requirements, and established procedures governing medical records. These guides are

general in nature and do not cover all areas of the work performed by the medical record

technician, such as cases involving new diseases or treatments or experimental drugs.

The employee uses judgment to adapt and interpret guidelines for application to specific cases

or problems, using discretion and initiative in deciding on the appropriate course of action to

correct deficiencies and improve reliability of information in the records. This may require

developing approaches and work methods within the framework established by higher level

authority, devising procedures to use when applying new regulatory requirements, or adapting to

new computer technology.

FACTOR 4, COMPLEXITY

Level 4-1 -- 25 Points

Employee performs clear-cut, repetitive, and interrelated tasks, such as assembling the medical

record in proper sequence and checking the medical record to insure all necessary forms are

present.

The nature of the work provides little opportunity for employees to decide what is to be done.

The employee performs assignments with few variations and with little likelihood of

complications. Standard operating procedures and instructions directly apply.

Level 4-2 -- 75 Points

Assignments are to solve routine problems of limited complexity. The work consists of duties

involving related steps, processes, or methods such as compiling, recording, and reviewing

medical record data. There are established procedures for performing the work.

Decisions about what needs to be done involve various choices requiring the technician to

recognize the existence of and differences among a few easily recognizable alternatives. The

work includes such tasks as determining which code, from several choices, most accurately

describes the diagnosis and the surgery performed; relating the operation to the proper diagnosis

when multiple diagnoses are listed; determining the final diagnosis rather than an initial or

consultative diagnosis; and assigning the DRG's while staying within the regulatory framework.

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The technician corrects technical errors using prescribed methods and performs other checks

to be sure of the validity of information.

Level 4-3 -- 150 Points

The work includes the performance of different and varied medical record processes and

methods. The technician performs periodic reviews of the work and that of other employees in

compliance with the regulatory requirements.

Decisions about what needs to be done require the employee to determine the relevance of

many facts and conditions such as information within the record, legal and regulatory

requirements, and other variables. The chosen course of action may have to be selected from

many alternatives, for example, when standardized procedures are silent on an issue.

The work involves analyzing and interpreting conditions and elements to correct complicated

inconsistencies or discrepancies in the records.

FACTOR 5, SCOPE AND EFFECT

Level 5-1 -- 25 Points

The work involves performance of specific and routine duties that include a few separate tasks

or procedures such as compiling data, answering specific questions for which information is

readily available, filing, or retrieving records.

The work facilitates the work of others in the immediate work unit or aids medical records

personnel in the same organization.

Level 5-2 -- 75 Points

The work involves performance of assignments according to specific rules or procedures

which represent a significant segment of the medical record function. For example, the employee

analyzes medical records information to ensure compliance with procedural requirements, codes

diseases and operations, and compiles other medical information.

The work affects the accuracy, timeliness, reliability, and acceptability of information in the

medical record.

Level 5-3 -- 150 Points

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The work involves performance of a variety of specialized medical records tasks and resolving

problems according to established criteria. For example, the employee processes medical records

and data that involve inconsistencies, discrepancies, and other nonroutine problems.

The work typically has a direct effect on medical recordkeeping and a direct impact on the

accuracy, timeliness, and reliability of some medical record services.

FACTOR 6, PERSONAL CONTACTS

AND

FACTOR 7, PURPOSE OF CONTACTS

Match the level of assigned, recurring personal contacts with their purpose and credit the

appropriate point value using the chart below.

Persons Contacted

1. Contacts are with employees within the immediate organization or work unit and in related or

support units. Contacts with members of the general public take place in highly structured

situations where, for example, the purpose of the contact and the question of with whom to

deal are relatively clear.

2. Contacts are with employees in the same agency, but outside the immediate organization.

Contacts with members of the general public take place in a moderately structured setting.

For example, the contacts are generally established on a routine basis, usually at the

employee's work place; the exact purpose of the contact may be unclear at first to one or more

of the parties; and one or more of the parties may be uninformed concerning the role and

authority of other participant. Examples of contacts include representatives of state agencies,

court officials, and insurance companies.

Purpose

a. To exchange factual information.

b. To coordinate work efforts and solve technical problems.

P U R P O S E

a b

1 30 60

2 45 75

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FACTOR 8, PHYSICAL DEMANDS

Level 8-1 -- 5 Points

The work is primarily sedentary. The employee sits comfortably to do the work. However, there

may be some walking, standing, or carrying of light items such as manuals and files. The work

does not require special physical demands.

Level 8-2 -- 20 Points

The work requires physical exertion such as prolonged periods of standing, bending, reaching,

and lifting moderately heavy items such as record boxes.

FACTOR 9, WORK ENVIRONMENT

Level 9-1 -- 5 Points

The work environment involves everyday risks or discomforts which require normal safety

precautions typical of such places as medical facility offices. There is adequate light, heat, and

ventilation in the work area.