Series established May 9, 1973
This series specification describes four classes involved in a wide range of health record processing functions. Incumbents abstract, code, collate, and review data from medical records, laboratory records, vital records, and other related sources. Work assignments are varied and may require both office work in departmental health data programs and field work in hospitals, doctors' offices, outpatient clinics, and other facilities.
Variety and complexity of assigned duties; independence of actions and decisions; knowledge of coding and health record systems and methodology; discriminating judgment necessary to evaluate technical abstracting and coding problems; nature and level of public contacts; degree and level of supervision received; degree and level of administrative, training, and supervisory responsibilities exercised, and extent of consequence of errors.
This is the general entry level into this series and the journeyperson level for persons assigned specifically to coding or other comparable health record processing functions. Under close supervision, works with relatively structured records; and learns the principles of health data processing including detailed coding and basic abstracting.
This is the journeyperson level in this series. Persons in these positions abstract diagnostic and treatment information from hospital medical records; convert data collected into a form for statistical use; and perform other related duties.
This is the first supervisory level in this series. Positions supervise five or more persons doing routine coding work; review prepared abstracts for completeness, clarity and quality of content; assist in the training and instruction of records personnel in facilities providing data; may write reports of findings; and perform other related duties.
This is the second supervisory level in this series. As a supervisor, under general direction, plans, organizes and assigns work areas to record coders and abstractors; resolves difficult technical abstracting and coding problems; analyzes quality control activities; acts as a consultant to records personnel in hospitals, laboratories, clinics and registries; conducts training activities and workshops; gives lectures; and consults with and advises superiors on operational matters,
Education Requirements: Equivalent to completion of the twelfth grade. (Additional qualifying experience may be substituted for the required education on a year-for-year basis.)
One year of California state service clerical experience which includes training and supervised work experience in the procurement and processing of health data.
Two years of clerical experience in the medical or health records section of a health facility. (Successful completion of an academic curriculum in medical records science in an accredited school may be substituted for the required general experience on a year-for-year basis.)
Two years of experience in the California state service performing the duties of a Health Record Technician I.
Four years of increasingly responsible medical or health records experience, performing a variety of tasks including at least two years of coding, indexing, and abstracting health data. (Successful completion of an academic curriculum in medical records science in an accredited school may be substituted for the required general experience on a year-for-year basis.)
Two years of experience performing the duties of a Health Record Technician II (Specialist) or Health Record Technician II (Supervisor).
Knowledge of: Basic medical terminology, human terminology and human anatomy; health record systems and methodology used by health facilities; classification of morbidity and mortality information for statistical purposes.
Ability to: Understand and conform to specific basic principles and rules of health data abstracting and coding; meet and deal tactfully with the public; communicate effectively; and benefit from academic and in-service training and job experience.
Knowledge of: In addition to the above, must possess a detailed knowledge of the various record systems used by health facilities; diagnostic techniques and modes of therapy as well as gross anatomy and medical terminology; an understanding of the principles of effective supervision and maintenance of good public relations; the Department's Affirmative Action Program objectives; a manager's role in the Affirmative Action Program and the processes available to meet affirmative action objectives.
Ability to: In addition to the above, must have the ability to analyze situations accurately and take effective action; plan, organize, train and direct the activities of a group of health record technicians; and effectively contribute to the Department's affirmative action objectives.