Medical Records Technician (Health Information Technician)

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. BASIC REQUIREMENTS. a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) b. Experience and Education. (1) Experience.

One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records. Six months of the required one year of creditable experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform MRT HIT work. OR, (2) Education. An associate's degree from an accredited college or university recognized by the U.S.

Department of Education, with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy, physiology, legal aspects of health care, and introduction to health records). OR, (3) Experience/Education Combination.

Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements.

The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one year above high school with a minimum of six semester hours of health information technology/health information management. (b) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the U.S.

Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience, provided the training program included courses in anatomy, physiology, and health record techniques and procedures. c. Grandfathering Provision.

All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard, are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation.

For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees in an occupation that does not require a licensure/certification/ registration, may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. (2) Employees appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. (3) Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials, as a condition of employment in the occupation. a.

Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service. b. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f). 5. GRADE REQUIREMENTS. All MRT HIT employees assigned to this occupation must have an approved parenthetical title as described below: a. MRT (HIT); b. Lead MRT (HIT); or c. Supervisory MRT (HIT). 6. GRADE DETERMINATIONS a.

Medical Records Technician (HIT), GS-4 (Entry Level) (1) Experience or Education. None beyond basic requirements. b. Medical Records Technician (HIT), GS-5 (Developmental Level 1) Experience. One year of experience equivalent to the next lower level. OR, Education. A bachelor's degree from an accredited college or university recognized by the U.S.

Department of Education with a major field of study in health information management, or a related degree with a minimum of 24 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy & physiology, legal aspects of health care, and introduction to health records). Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to communicate effectively with internal and external customers. (b) Ability to utilize health information technology and various office software products used in health information management positions (e.g., Microsoft Excel, electronic health records, and delinquency tracking software). (c) Knowledge of health record documentation guidelines and industry standards. (d) Ability to manage priorities and coordinate work to complete duties within required timeframes. (e) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record. c.

Medical Records Technician (HIT), GS-6 Experience. One year of experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to navigate efficiently through the health record to locate needed information. (b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards. (c) Skill in investigating potential health record errors and making corrections, when appropriate. (d) Skill in interpreting and applying health information guidelines and using 6 judgment to complete assignments. (e) Ability to follow up on incomplete health record documentation. d.

Medical Records Technician (HIT), GS-7 (Full Performance Level). Experience. One year of experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to judge whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support education and research needs. (b) Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable. (c) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations. (d) Skill in using appropriate software and computer applications to analyze and record documentation trends.(e) Ability to apply qualitative and/or quantitative methods for assessment and 7 improvement of health records. (f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work.

01Continued in the Education section

The duties of the Medical Records Technician (Health Information Technician) include, but are not limited to: The incumbent is responsible for abstraction of clinical information for ongoing regulatory reviews and deficiency analysis. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists clinical staff by providing information as to required documentation.

• Communicates very closely with the clinical staff to answer questions and resolve problems to ensure quality documentation in the health records.
• Assists with capture and reporting of health record documentation deficiencies and notates documentation deficiencies in the appropriate deficiency monitoring application.
• Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records.

Notifies appropriate physician and other personnel of the status of dictation. Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records prior to departure from the Medical Center. Participates in approved quality improvement focused reviews. Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects.

Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and to satisfy current Medical Center performance measures. Collects data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking.

Tracks unsigned/un-cosigned notes (e.g., progress notes, operative reports, discharge summaries, etc.) and encounters without associated progress notes, and communicates these deficiencies to clinical staff for completion. Assists with capture and reporting of health record documentation deficiencies and notates documentation deficiencies in the appropriate deficiency monitoring application.

Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records. Notifies appropriate physician and other personnel of the status of dictation. Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records prior to departure from the Medical Center.

Assists physicians with the completion of delinquent/incomplete health records and servers as the expert resource for clinical staff regarding requirements for complete documentation. Prepares complex reports on a routine basis, noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff.

Reviews health records to ensure that all records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs. Notifies clinicians of missing, incomplete, or inaccurate information in their signature blocks (e.g., missing or inaccurate credentials). Assists clinicians with completion of delinquent/incomplete health records.

Works independently to resolve incomplete health record deficiency and erroneous documentation issues and only seeks guidance of immediate supervisor when issues surface where no precedent or procedure has been developed. Collects, interprets, and trends data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking.

Participates in routine and focused reviews for the purpose of identifying problems and potential problems in health record documentation as part of the health record review process. Identifies and abstracts information from health records for special studies and audits both internal and external. Work Schedule: Monday - Friday, 7:30 am - 04:00 pm, (Subject to change based on the needs of the facility.) Telework: Available Virtual: This is not a virtual position.

Functional Statement #: 01300F, 01301F, 01437F, 01438F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized