Class Code: 9758-10 Date Established: 01-23-84


Occupational Code: 1-2-2 Date of Last Revision: 05-02-11


BASIC PURPOSE: To perform clerical duties in compiling, retrieving, filing and monitoring patient medical records in a hospital nursing unit of a health care facility.




           Processes inpatient admissions and discharges to ensure all necessary sections on patient records are recorded.

           Receives, sorts and files reports and other medical documents into patients’ medical records alphabetically, numerically or by other established classification.

           Maintains and monitors medical records to insure that patient records are up-to-date and complete.

           Verifies authorizations for access to medical records to insure patient confidentiality and monitors file sign-out, delivery and retrieval; transmits correspondence and medical records by mail, e-mail, or fax as requested.

           Types forms, labels and other preliminary paperwork on patients for use by clinical or nursing staff.

           Enters and edits patient information in computer databases or systems and compiles and records medical charts, reports, and correspondence using notes, typewriter, or personal computer.

           Responds to inquiries from other personnel and provides routine information pertaining to a hospital nursing unit.

           Operates office machines, such as photocopiers and scanners, facsimile machines, voice mail systems, and personal computers.

           Maintains inventory of office supplies for a hospital ward or health facility.

           Answers telephones, relays messages and schedules medical appointments as required by the agency.





Skill: Requires skill in recommending routine changes in standardized operating procedures OR in retrieving, compiling, and reporting data according to established procedures OR in operating complex machines.


Knowledge: Requires understanding and using business or trades vocabulary or basic arithmetic to perform standard operating procedures.


Impact: Requires responsibility for contributing to agency objectives by ensuring the accuracy of support activities within one or more organizational units. Errors at this level affect the work of others or have measurable monetary consequences, and require immediate verification and correction in order to complete succeeding work operations.


Supervision: Requires no supervision of employees or functions.


Working Conditions: Requires performing regular job functions in an environment which includes exposure to continuous physical elements or a number of disagreeable working conditions with frequent exposure to minor injuries or health hazards.


Physical Demands: Requires light work, including continuous walking or operating simple equipment for extended periods of time as well as occasional strenuous activities such as reaching or bending.


Communication: Requires obtaining and exchanging information, referring inquiries to the appropriate source, or responding to questions from state employees or members of the general public.


Complexity: Requires a combination of job functions using minimal judgment to perform a variety of job tasks according to clearly prescribed standard practices and procedures.


Independent Action: Requires a range of choice in applying a number of technical or administrative policies under general direction and making routine decisions or in recommending modifications in work procedures for approval by supervisor.




Education: Completion of high school, G.E.D. or its equivalent. Each additional year of approved formal education may be substituted for one year of required work experience.


Experience: Two years’ experience performing clerical work or two years’ experience as a Mental Health Worker or in the field of health care involving medical record documentation skills.


License/Certification: None required.


RECOMMENDED WORK TRAITS: Knowledge of medical technology, business English, English grammar, spelling, punctuation and arithmetic. Knowledge of medical office practices, procedures and equipment. Working knowledge of filing techniques. Knowledge of telephone answering procedures. Ability to maintain departmental records and clerical reports from such records. Ability to accurately coordinate and organize large volumes of documentation for multiple individuals utilizing various entry and retrieval systems. Ability to follow simple instructions. Ability to learn assigned clerical tasks readily and adhere to prescribed routines. Ability to establish and maintain effective working relationships with other employees and the general public. Must be willing to maintain appearance appropriate to assigned duties and responsibilities as determined by the agency appointing authority.


DISCLAIMER STATEMENT: This class specification is descriptive of general duties and is not intended to list every specific function of this class title.



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