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Job Description for a Medical Abstractor

Using knowledge of medical terminology and coding, medical abstractors analyze patient records and other medical data for physicians, researchers and other agencies. Becoming a medical abstractor requires only a high school diploma and clerical or coding experience. An associate or bachelor's degree program and certification,, however, is highly regarded by employers.

Main Job Responsibilities

For medical research purposes or to create medical recognition programs, medical abstractors analyze and compile medical information based on paper and electronic charts; patient and physician interviews; and various other sources. In this position, you examine codes and charts, and investigate information that might be missing. Using your coding and research skills, you compile reports that help researchers or physicians prevent diseases or recognize common characteristics for life-threatening diseases. For example, you may work for medical associations that create diabetes recognition programs. You typically work a 40-hour workweek in an office setting, and most positions are found through health or research facilities.

A Day in the Life

A medical abstractor enters abstracted data -- pertinent diagnosis, prognosis and treatment data from medical charts -- into a database, and works with physicians and staff to find information or pull specific charts. You track routine statistics, analyze variables in patients and review data for completeness. You also collect followup data and correspond with physicians about incomplete charts or data. Part of your job is to create detailed summaries of a patient's treatment and prognosis, and organize and maintain databases. Administrative tasks may also be part of your job.

Knowledge You Need

Knowledge of medical terminology and coding is essential for this position. Analytical skills and attention to detail are necessary to understand and follow medical records, and determine errors or missing information. Because medical records are confidential, you must exercise integrity to protect patient confidentiality. Technical skills with database and coding software are also necessary, as well as strong computer skills. You must have excellent oral and written communication skills to converse with physicians and other employees.

Education & Training

Breaking into this field requires only a high school diploma. However, formal education -- such as an associate or bachelor’s degree in healthcare, medical coding or health information technology -- is preferred by most employers. Look for programs accredited by the American Health Information Management Association, or AHIMA. Most employers call for three or more years working in medical coding. While not required, professional certification through the AHIMA is also an asset.



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