Medical Record Consultant
California State Personnel Board Specification
Definition
Under general direction in the Bureau of Health Facilities Licensing and Certification, Department of Developmental Services, to develop methods and coordinate procedures for the recording and transcription of significant patient data in hospital medical records; to conduct studies and provide consultation on needs for and most effective means of recording, collecting and analyzing patient care data to meet standards of public medical care programs; to plan and develop training programs and aids, and instruct Medical Record Officers; and to do other related work.
Typical Tasks
Consults with records personnel, physicians, hospital administrators, and nurses on the extent and nature of patient care information currently recorded in admission, discharge, clinical and other records in hospitals and related health facilities; assists in the design of standards and advises on feasibility and methods of obtaining significant data in hospital records and health facility; identifies data including indexes of patient flow, use of specialized services, population characteristics conducive to hospital use and other data which may be obtained from or integrated into hospital medical records; develops experiments of medical records procedures to record and transcribe necessary data and investigates and evaluates their applicability to hospital systems; analyzes the potentials and limitations of medical records systems as sources of hospital planning data; meets with and works with hospital administrators, nursing directors and supervisors, Medical Record Officers, and other hospital personnel to obtain cooperation in meeting standards for medical records in public medical care programs and to coordinate application of experimental procedures, including resolution of problems, and provisions of assistance in installing and making adjustments of medical records systems and procedures, reviews data reported for adequacy of standards and reporting procedures, and checks, interprets and advises on such matters as Standard Nomenclature, National Health Surveys, International Statistical Classification and legal aspects of medical records maintenance and reporting; prepares manuals, training aids and organized training programs as required; maintains close liaison with hospitals, medical records librarian associations and other pertinent organizations and professional groups.
Minimum Qualifications
Registration by the American Association of Medical Record Librarians as a Registered Record Librarian or eligibility for examination for registration. (Applicants who are not Registered Record Librarians will be admitted to the examination, but they must secure the certificate of registration, or submit proof of eligibility for examination for registration as evidenced by a statement from the Association before they will be considered eligible for appointment.) and Experience: Three years of increasingly responsible experience in planning, organizing, and directing all medical records activities in a hospital or related health facility including developing and installing medical records systems and providing reference, research, and consultive service for professional staff including interns, residents, and fellows. and Education: Equivalent to graduation from college. (Additional qualifying experience may be substituted for the required education on a year-for-year basis.)
Knowledge and Abilities
Knowledge of: The principles, standard practices and techniques in the field of medical record library science; principles and methods utilized in the organization and management of medical records departments; current trends and developments in medical record library methods and procedures; the application of various indexing methods to classification systems and skill in the operation and use of various indexes to clinical material in medical records; hospital organization and management and the relation of the medical records program to hospital functions and programs; social and economic factors in relation to the planning and use of hospitals and related medical facilities; relationships among various welfare, social, public health, and medical organizations and agencies in the hospital field; research methods and procedures and statistics; the problems attendant to hospital planning; Department's Affirmative Action Program objective; a manager's role in the Affirmative Action Program and the processes available to meet affirmative action objectives.
Ability to: Establish and maintain cooperative relationships; plan and conduct training and instructive programs; speak and write effectively; effectively contribute to the Department's affirmative action objectives.
Special Personal Characteristics
Willingness to travel throughout the State; perseverance, tact, keenness of observation, and neat personal appearance.
