Using medial terminologies, and coding, a Medical Abstractor analyses patient records and other medical data for researchers, physicians, or other agencies. Primary responsibilities associated with the role are listed on the Medical Abstractor Resume as – analyzing and compiling medical information based on paper and electronic charts, patient and physician interviews, and various other sources; examining codes and charts, investigating information that is missing, entering abstracted data from medical charts into a database, tracking routine statistics, analyzing variables in patients and reviewing data for completeness; collecting follow-up data, corresponding with physicians about incomplete charts, creating detailed summaries of patient’s treatment, and maintaining databases. The job description also includes certain administrative tasks.
Being well-versed in medical terminology and coding is vital for this role. Attention to detail and analytical skills are necessary for understanding and following the medical records, the ability to determine errors and keeping the medical records confidential are essential. Breaking into this career needs just a high school diploma or GED, however, some employers prefer hiring those with a degree in healthcare, health information technology, or medical coding.
Objective : Results-oriented Medical Records Abstractor with 5 years of experience in accurately extracting and managing patient data. Demonstrates expertise in compliance, data integrity, and collaboration with healthcare teams to enhance record accuracy. Passionate about streamlining processes while ensuring patient confidentiality and high-quality documentation, contributing significantly to improved healthcare outcomes.
Skills : Data Management Software, EMR/EHR Systems, Data Analysis, Medical Terminology
Description :
Abstracted critical data from hospital medical records to fulfill specialized information modules.
Conducted regular training sessions to ensure staff proficiency in current medical documentation standards.
Reviewed and documented key patient information, including demographics, medical history, and treatment details, ensuring accuracy and compliance.
Evaluated and verified the validity of abstracted data, addressing discrepancies and ensuring data integrity.
Consistently achieved and surpassed productivity and accuracy targets in data management.
Maintained confidentiality and integrity of sensitive patient information in accordance with HIPAA regulations.
Adapted swiftly to changes in documentation guidelines and client requirements, ensuring seamless workflow transitions.
Experience
2-5 Years
Level
Executive
Education
A.A.S. in HIM
Medical Records Abstractor Resume
Objective : Committed Medical Records Abstractor with 5 years of experience in precise data extraction and management. Proven expertise in maintaining compliance, ensuring data integrity, and collaborating with healthcare professionals. Driven to optimize documentation processes while safeguarding patient confidentiality, ultimately enhancing healthcare delivery and outcomes.
Skills : Healthcare Data Coding, Insurance Claims Processing, Data Entry, HIPAA Compliance, Quality Assurance
Description :
Utilized data abstraction guidelines to extract critical information from medical records for compliance with CMS requirements.
Consistently maintained an accuracy score exceeding 95% and a productivity score above 90%.
Abstracted hospital inpatient quality measures, focusing on the Surgical Care Improvement Project (SCIP).
Gathered and abstracted outpatient quality measures, including ED-Throughput and Pain Management metrics.
Entered and verified abstracted data in computerized systems for quality assurance and analytics.
Ensured the confidentiality and security of sensitive medical records in compliance with HIPAA regulations.
Reviewed medical records to collect clinical data according to established specifications and guidelines.
Experience
2-5 Years
Level
Executive
Education
AAS-HIT
Medical Records Abstractor Resume
Headline : Proficient Medical Records Abstractor with a commitment to maintaining confidentiality and compliance. Successfully trained new staff on best practices, fostering a culture of accuracy and efficiency in record-keeping.
Skills : Paragon Health Information System, PowerChart EHR, Lawson Healthcare Management, Flowcast Data Management, USA Health Compliance Standards
Description :
Accurately entered data in cart and abstraction software to maintain data integrity.
Adhered to established processes and procedures to ensure compliance with regulations.
Followed up with healthcare providers to secure missing documentation, enhancing record completeness.
Tracked all record results of accounts to ensure data accuracy and reporting.
Collaborated with Quality Management to address issues impacting core measures effectively.
Reviewed and analyzed relevant medical diagnoses from various clinical documents for accuracy.
Applied data collection guidelines to determine eligibility for inclusion in datasets.
Experience
5-7 Years
Level
Executive
Education
BSHIM
Medical Abstractor Resume
Objective : Detailing two years as a Medical Abstractor, I excel in extracting and organizing medical data while ensuring compliance with regulations. My focus on data integrity and confidentiality drives accuracy in documentation. I collaborate effectively with healthcare teams to enhance record management processes, contributing to improved patient outcomes and streamlined workflows.
Skills : Data Abstraction Techniques, Statistical Analysis, Report Writing, Information Retrieval, Coding Proficiency
Description :
Streamlined access to patient data by effectively managing Electronic Medical Record systems.
Utilized extensive knowledge of medical terminology to extract and verify patient information from charts.
Ensured compliance with HIPAA regulations while inputting clinical data into EMR templates.
Digitized and transferred medical records to enhance electronic documentation efficiency.
Collaborated with healthcare teams to improve data management processes.
Conducted regular audits to maintain record accuracy and compliance.
Provided feedback to improve EMR usability based on user experiences.
Experience
0-2 Years
Level
Entry Level
Education
AAS-HIT
Senior Medical Abstractor Resume
Summary : Accomplished Senior Medical Abstractor with a decade of experience in meticulously reviewing and extracting critical medical data. Expertise in regulatory compliance, medical coding, and collaboration with healthcare teams to enhance patient record accuracy. Passionate about upholding patient confidentiality and improving data management processes across healthcare settings.
Skills : Communication Skills, Team Collaboration, Data Interpretation, Statistical Analysis, Health Information Systems
Description :
Provided comprehensive support in reviewing and abstracting medical records, ensuring adherence to compliance guidelines.
Collaborated with healthcare professionals to enhance patient care through accurate documentation.
Utilized electronic health record systems for efficient data management and retrieval.
Maintained patient confidentiality and data integrity in all interactions and documentation.
Conducted training sessions for staff on compliance and data entry best practices.
Assisted in the development of procedural manuals and guidelines for medical record abstraction.
Participated in quality assurance initiatives to improve data accuracy and reporting.
Experience
7-10 Years
Level
Senior
Education
BSHIM
Medical Abstractor Resume
Headline : Experienced Medical Abstractor with over 7 years in reviewing and extracting vital medical data from patient records. Proficient in ensuring compliance with healthcare regulations and maintaining patient confidentiality. Adept at utilizing advanced data management systems to enhance record accuracy and streamline workflows across clinical settings.
Skills : Data Abstraction, Quality Assurance, Documentation Review, Workflow Optimization, Data Security, Project Management
Description :
Reviewed clinical documentation to accurately extract and abstract medical data for quality improvement initiatives.
Utilized advanced database systems to input and manage data efficiently, ensuring confidentiality and compliance.
Collaborated with clinical supervisors and specialists to enhance data collection tools and workflows.
Participated in studies focusing on Pneumonia and Surgical Site Infections, providing support to fellow abstractors.
Communicated effectively with clinical teams regarding chart completion and data accuracy.
Maintained up-to-date knowledge of healthcare regulations and best practices in medical abstraction.
Conducted audits of abstracted data to verify accuracy and compliance with established protocols.
Experience
5-7 Years
Level
Senior
Education
BSHIM
Junior Medical Abstractor Resume
Objective : Dedicated Junior Medical Abstractor with 5 years of experience in meticulously reviewing and abstracting medical records. Proficient in ensuring regulatory compliance and maintaining patient confidentiality while optimizing data management. Eager to enhance the accuracy of medical documentation and contribute effectively to healthcare teams.
Skills : Electronic Health Record Management, Problem Solving, Patient Interaction, Report Writing, Data Entry Accuracy, Patient Records Management
Description :
Executed data extraction and abstraction to ensure compliance with healthcare regulations.
Reviewed medical records for accuracy, identifying discrepancies and ensuring data integrity.
Collaborated with healthcare teams to enhance patient record accuracy and streamline documentation processes.
Maintained meticulous records of patient information and data entries, achieving a 98% accuracy rate.
Participated in quality control audits to validate the accuracy of medical data entries.
Utilized advanced data management systems to facilitate efficient retrieval and processing of medical records.
Trained and mentored new staff on best practices for data abstraction and compliance standards.
Experience
2-5 Years
Level
Junior
Education
AAS HIT
Medical Abstractor Resume
Summary : With a decade of expertise as a Medical Abstractor, I specialize in the precise extraction and documentation of medical data while ensuring compliance with HIPAA regulations. My proficiency in data management systems enhances accuracy and efficiency in patient records. I am dedicated to maintaining confidentiality and improving healthcare documentation processes, contributing to better patient outcomes.
Compiled and analyzed clinical data for reporting to various departments, acting as a vital liaison for quality improvement initiatives.
Maintained quality databases by loading import files and generating status reports, ensuring adherence to regulatory timelines.
Identified trends in clinical data, providing actionable insights to leadership for informed decision-making.
Collected diverse data from medical records, clinical systems, and external databases while ensuring accuracy and compliance.
Extract and analyze medical data from patient records for research purposes.
Generated detailed reports on clinical measures for accreditation and compliance, supporting administrative and clinical teams.
Conducted thorough data retrieval, aggregation, and analysis, enhancing data-driven decision-making across departments.
Experience
10+ Years
Level
Executive
Education
BSHIM
Lead Medical Abstractor Resume
Summary : Seasoned Medical Abstractor with 10 years of extensive experience in accurately reviewing and extracting critical medical data from patient records. Adept at ensuring compliance with healthcare regulations and utilizing advanced data management systems to enhance data integrity. Committed to upholding patient confidentiality while improving documentation processes to support optimal patient outcomes.
Skills : Data Analysis Skills, Medical Terminology, Data Entry, Clinical Research
Description :
Provided leadership in performance improvement initiatives to enhance patient safety and data accuracy.
Conducted comprehensive audits of medical records to ensure compliance with regulatory standards.
Verified the accuracy of medical records, producing detailed reports for management review.
Maintained compliance with all Service Level Agreements (SLAs) outlined in project assignments.
Consistently achieved an abstracting accuracy rate of 95% or higher.
Collaborated with Registry Manager to optimize abstracting workflows and processes.
Trained and mentored junior abstractors on best practices and compliance protocols.
Experience
7-10 Years
Level
Management
Education
B.S. in HIM
Medical Abstractor Resume
Objective : Proficient Medical Abstractor with two years of experience in extracting and documenting medical data from patient records. Adept at ensuring compliance with healthcare regulations and maintaining confidentiality. Focused on enhancing data accuracy and supporting healthcare teams through effective communication and collaboration.
Skills : Data Management, Healthcare Regulations, Research Methodology, Abstract Writing, Critical Thinking, Data Collection
Description :
Completed weekly productivity reports in centralized database accurately and on time.
Participated in new hire training and annual quality reviews.
Monitored workload assignments to ensure timely completion of tasks.
Engaged in monthly meetings to discuss education topics and data trends.
Developed strong working relationships with medical staff and leadership for project collaboration.
Ensured comprehensive cancer-related information was available for the Cancer Registry.
Submitted data to state and national registries as required by management.
Experience
0-2 Years
Level
Fresher
Education
AAS HIT
Assistant Medical Abstractor Resume
Headline : Accomplished Assistant Medical Abstractor with 7 years of expertise in meticulously reviewing and abstracting medical records. Proficient in ensuring compliance with healthcare regulations and maintaining patient confidentiality. Committed to enhancing data accuracy and streamlining documentation processes to support healthcare teams and improve patient outcomes.
Skills : Attention To Detail, Electronic Health Records, Confidentiality Standards, Medical Research, Clinical Trials Knowledge, Ethical Standards
Description :
Abided by the American Health Information Management Association's code of ethics to promote quality and efficiency in healthcare.
Carefully abstracted required data elements from medical records for regulatory compliance.
Reviewed and resolved discrepancies in data entry to ensure accuracy.
Participated in regular data quality assessments to maintain high standards.
Assisted in verifying summary data before publication, contributing to accurate reporting.
Updated knowledge of regulatory changes affecting medical data management.
Utilized advanced data management software to input and analyze medical data effectively.
Experience
5-7 Years
Level
Executive
Education
A.S. HIT
Medical Abstractor Resume
Objective : Accomplished Medical Abstractor with 5 years of experience in the thorough review and abstraction of medical records. Expertise in ensuring compliance with healthcare regulations and maintaining confidentiality. Proven ability to enhance data accuracy through efficient data management and collaboration with healthcare teams.
Skills : Database Management, Healthcare Analytics, Medical Coding, Chart Review, Information Retrieval, Organizational Skills
Description :
Demonstrated expertise in disease processes, anatomy, and physiology for accurate coding.
Adhered to ICD-10 and CPT guidelines for coding visits and procedures.
Applied CMS and local guidelines for evaluation and management coding.
Knowledgeable in federal and state regulations related to patient information.
Interpreted coding information for healthcare professionals to enhance understanding.
Ensured compliance with principles regarding fraud and abuse in healthcare.
Maintained accurate records to support billing and reimbursement processes.
Experience
2-5 Years
Level
Junior
Education
AAS HIT
Medical Abstractor Resume
Summary : Accomplished Medical Abstractor with 10 years of experience in the meticulous extraction and documentation of medical data. Proficient in ensuring regulatory compliance and utilizing advanced data management systems to improve data integrity. Dedicated to maintaining patient confidentiality while optimizing documentation processes and enhancing overall healthcare outcomes.
Skills : Data Management Planning, Research Skills, Data Reporting, Clinical Guidelines, Time Management
Description :
Reviewed, analyzed, and abstracted comprehensive medical data from electronic health records to support patient care and research initiatives.
Ensured compliance with HIPAA regulations while maintaining the confidentiality of sensitive patient information.
Conducted quality audits and provided actionable feedback to enhance data accuracy and integrity.
Collaborated with cross-functional teams to optimize data management processes and improve overall workflow efficiency.
Utilize electronic health record systems for data entry and retrieval.
Generated regular reports on data quality metrics to inform departmental decision-making.
Updated and maintained procedural documentation to reflect current practices and compliance standards.
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