Patient Records Abstractor

Class Specifications – H.45
4716 – Patient Records Abstractor IV
4717 – Patient Records Abstractor III
4718 – Patient Records Abstractor II
4719 – Patient Records Abstractor I

October, 1975

Series Concept

Patient Record Abstractors analyze, abstract, and compile medical information from patients’ records as a service to physicians, researchers, and various agencies and business offices associated with patient care; and perform other related duties as required.

Essential elements of Patient Record Abstractor positions are: (1) a complete working knowledge of the applicable medical terminology; (2) an in-depth understanding of the meaning and organization of patient records; (3) an understanding of the relationship between patient records and the service to be provided to such diverse groups as hospital business offices, insurance companies, Medi-Cal, Medi-Care, and various other governmental agencies; and (4) analysis of the patient record.

Class Concepts

Patient Record Abstractor IV

Under direction, incumbents perform either supervisory duties over a department or section usually consisting of at least two Patient Record Abstractor IIIs or five Patient Record Abstractor IIs or equivalents; or non-supervisory duties requiring the highest level of skill and complexity described in the Series Concepts.

In addition to the requirements for an extensive knowledge of medical terminology and understanding of patient records, positions at this level may require special skills or knowledge in several areas, such as coding, data processing and billing systems, governmental systems and programs, and English composition. Non-supervisory positions at this level require analysis of problems equivalent to an entry level professional staff analyst.

Patient Record Abstractor IV positions differ from Patient Record Abstractor III positions in that they involve either greater supervisory responsibility over personnel in higher level classes or significantly more complex work.

Examples:

1. In a non-supervisory position within a Hospital Medical Correspondence Department, the incumbent abstracts an entire complex patient record such as a forty-page record covering a span of several years to create a one- or two-page summary including care, prognosis, and correlation of all available data for transmission to insurance companies, outside physicians and organizations.
2. In a supervisory position within a Hospital department serving a Professional Group, the incumbent serves as a first assistant to a higher level administrator in the daily supervision of a staff of more than two Patient Record Abstractor IIIs or five Patient Record Abstractor IIs.

Patient Record Abstractor III

Under general supervision, incumbents perform either supervisory duties over a department or section usually consisting of at least three Patient Record Abstractor IIs or at least five Patient Record Abstractor Is or equivalents; or non-supervisory duties requiring a high level of skill and complexity.

Non-supervisory positions at this level differ from Patient Record Abstractor IV positions in that they involve less varied types of skills and less complex work than is required of the Patient Record Abstractor IV class. The Patient Record Abstractor III class may be used for positions in which the incumbent has reached the advanced operational level of capability in work requiring complex skills in a limited variety of areas.

Supervisory positions at this level differ from those at the Patient Record Abstractor II level in that they usually involve full supervisory authority over a larger number of personnel in higher level classes whereas Patient Record Abstractor II positions may perform only as working supervisors, serve as technical resources, or exercise limited supervisory authority.

Examples:

1. In a non-supervisory position within a Hospital Medical Records Department Coding Section, incumbents perform complex and detailed coding of patient records for a data processing analysis and retrieval system at an advanced operational level of capability.
2. In a non-supervisory position within a Hospital Medical Correspondence Department, incumbents perform the duties normally performed by Patient Record Abstractor IIIs and, in addition, make comparative analyses requiring limited abstraction of a simple three- or four-visit patient record; and prepare original summaries explaining the disability to insurance companies and employers. This work requires recognition of medical information needed for release on a problem usually resulting from previously released billing and disability information.
3. In a supervisory position in a Hospital department serving a Professional Group, incumbents supervise a group of more than three Patient Record Abstractor IIs in the control, analysis, organization, and abstraction of patient records. Such work may also include peripheral tasks such as maintenance of patient indices.

Patient Record Abstractor II

Under supervision, incumbents perform duties primarily of a non-supervisory nature, but which may include supervision as a working leader; or act as a technical resource for Patient Record Abstractor Is.

Positions at this level involve the performance of the work described in the Series Concept at a moderate level of skill in work requiring interface in a limited variety of areas.

Examples:

1. In a Hospital Medical Correspondence Department, incumbents analyze patient records and provide service to outside organizations on less complex assignments such as writing brief letters to insurance companies concerning disability and billing information previously released. The analysis is limited to specific questions requiring detailed but non-research information.
2. In a Hospital Medical Records Department Coding Section, incumbents perform medical coding duties requiring good knowledge of medical terminology and the codes used on patient records at the operational level of capability.
3. In a Hospital Medical Records Department Discharge Analysis Section, incumbents perform as working leaders of Patient Record Abstractor Is and, in addition, perform such duties as verification and correction of statistical data abstracted and compiled by subordinates, reconciliation of output statistics, and medical coding.
4. In a Hospital department serving a Professional Group, incumbents perform a wide range of duties such as locating records, checking all billable procedures, ensuring that all items requested and all physicians’ notes are entered in the record, abstracting information, and solving day-to-day problems involving Relative Value System codes, physicians’ notes, and diagnoses.
5. In a Hospital Medical Records Department Medi-Cal Section, incumbents perform as working leaders over Patient Record Abstractor Is. In addition, incumbents prepare and process treatment authorization requests and other Medi-Cal forms requiring interface with physicians for completion.

Patient Record Abstractor I

Under close supervision, incumbents perform duties at a sub-operational level of skill in a limited variety of the areas described in the Series Concept. Positions at this level may also be used where the incumbent is receiving training and developing operational skills.

Minimum Qualifications

Patient Record Abstractor IV

Graduation from high school or a General Education Diploma with a demonstrated knowledge of the applicable medical terminology and four years of related hospital clerical experience, three of which must be in the type of work to be performed; or an equivalent combination of education and experience; and knowledges and abilities essential to the successful performance of the duties assigned to the position.

Patient Record Abstractor III

Graduation from high school or a General Education Diploma with a demonstrated knowledge of the applicable medical terminology and three years of related hospital clerical experience, two of which must be in the type of work to be performed; or an equivalent combination of education and experience; and knowledges and abilities essential to the successful performance of the duties assigned to the position.

Patient Record Abstractor II

Graduation from high school or a General Education Diploma with a demonstrated knowledge of the applicable medical terminology and two years of related hospital clerical experience, one of which must be in the type of work to be performed; or an equivalent combination of education and experience; and knowledges and abilities essential to the successful performance of the duties assigned to the position.

Patient Record Abstractor I

Graduation from high school or a General Education Diploma with a demonstrated aptitude for or knowledge of the applicable medical terminology and one year of applicable hospital clerical experience; or an equivalent combination of education and experience; and knowledges and abilities essential to the successful performance of the duties assigned to the position.