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.
Summary : Medical Abstractor is Performing a comprehensive review of medical records to identify and confirm disease diagnoses. Performing data entry of demographic and clinical data into a database management system. Coordinating multi-week travel to counties throughout the state by planning visits to multiple facilities, making travel arrangements and submitting travel. Establishing and maintaining working relationships with Health Information Management staff in statewide medical facilities to schedule appointments and request records for review.
Skills : Proficient in electronic medical records: EPIC, Medisoft,.
Description :
Helped physician access the critical information they need to practice quality medicine through Electronic Medical Record System.
Exhibited a thorough medical terminology and concepts and in-depth attention to details, to derived accurate information based on the patient's chart.
Handled the discrete data and populate the EMR templates with the clinical information that the physician needs to treat their patients.
Transferred data form medical charts to EMR System.
Complied to HIPPA law. Medical Record Abstractor Enter discreet data from paper medical record into EPIC medical record.
Coordinated audit schedule with system analyst and notify of any rescheduling needs.
Provided feedback to super user and other concerns related to charts.
Experience
10+ Years
Level
Senior
Education
BS In Nursing
Medical Abstractor Resume
Summary : To obtain and secure a Medical Abstractor position within a professional environment that will utilize my skills in leadership, strategic planning, problem-solving, and customer service skills. Contributing to the development of reports for team meetings and project progress reports, and procedure manuals and abstractor's handbooks for conducting enhanced birth defect surveillance.
Skills : In-depth knowledge of taking vital signs; temperature,.
Description :
Planned daily activities for service recipients and provide the supervision and/or assistance as needed for individual and group activities.
Provided physical assistance during meals and leisure times, and during personal care activities such as changing, showering, toileting, etc.
Provided assistance throughout the center or in the community.
Administered prescribed medications according to DDD and Agency Policies and procedures.
Protect the privacy and confidentiality of service recipients; understood and supported human rights and demonstrate respect for service recipients in all interactions.
Gained great experiences with working with special mental disable adults and some children and able to share some of my personal techniques to help them with every day life issues.
Used Premedication administer, completing goals, engagement.
Experience
10+ Years
Level
Senior
Education
BS In Nursing
Medical Abstractor Resume
Summary : Knowledge Management Professional with nearly 20 years experience in the Information Management Industry who possesses excellent communication and organizational skills. Proven track record of ability to work effectively both independently and in a team setting. Flexible, detail oriented, team player competent in abstract writing, proof reading, and editing, also in quality control, on line researching, modification, tracking, and cataloging of metadata in bibliographic records for United States Department of Education sponsored Education Resources Information Center (ERIC) digital library.
Skills : Abstract Writing, Proof Reading, Data Entry, Editing,.
Description :
Abstraction and Coding (CDAC) Medical Abstractor Reviewed clinical documentation and diagnostic results in patient records to extract analyze and retrieve data for quality monitoring, and improvement as required by state, federal, and private agencies.
Analyzed and keyed data into data base system using workflow software.
Ensured that all information was collected in a secure, organized, and confidential manner.
Collaborated with clinical supervisors, medical specialists, and tech team to constantly improve Accuracy and ongoing updates of on line work flow tools by regularly providing feedback and testing new tools for metadata collection as they were being developed.
Identified significant data trends.
Participated in Pneumonia, Surgical Site Infections studies, and assisted other abstractors with additional studies per request of clinical supervisors.
Notified super user, designated clinical system analyst of scheduling and completion of charts.
Experience
7-10 Years
Level
Management
Education
GED
Medical Abstractor Resume
Summary : To work in the human resources and training field to serve employees that need continuing education and/or to gain skills to be able to perform their job duties at an optimal level. Scanning patient documentation into an imaging system. Accurately reviewing and abstracting medical information to determine the correct patient, date of service, provider, type of service, and indexes patient documentation to correct record.
Skills : Microsoft Office, Medical Terminology, Data Entry, Filing, Customer Service, Typing 40+ Wpm.
Description :
Performed exports of data to software vendor to meet PHC4 regulations as needed.
Used Chart Locator to sign out charts and make inquiries.
Ensured all open-heart cases are accurately identified.
Located and entered all needed open-heart data elements into PHC4 open heart application.
Reviewed and processed as appropriate PHC4 edits related to the lab export, open heart data elements and assists with other data edits as appropriate.
Verified all patient information before abstracting patient chart Time Management Excellent attention to details Attend conference calls Review records.
Performed primary data abstraction duties for clinical measures and registries while ensuring high levels of abstraction accuracy and ensure alignment with organizational quality standards.
Experience
7-10 Years
Level
Management
Education
Bachelor Of Science In Nursing
Medical Abstractor Resume
Headline : Medical Abstractor with 6 years of experience in Utilizing all online systems (Financial and clinical) to determine correct document type and source. Acquiring and maintaining a thorough working knowledge MGH information system necessary to process documents (i.e. Epic Hyperspace Chart release and LMR). Acquiring and maintaining a thorough working knowledge of HIPAA, MGL, and MGH processes and systems.
Skills : Planning, System Assistant.
Description :
Compiled data into reports for analysis by various departments and committees and act as liaison between clinical improvement teams to interpret standards and specifications.
Maintained various quality databases including loading import files, generating and working data status reports in compliance with regulatory requirements and time-frames.
Identified and communicated trends in clinical data to leadership.
Collected data from various sources including medical records, clinical information systems, log/record, interview, national and state databases and governing organizations.
Managed requests for data and provide comprehensive quality management reports including utilization, outcome studies and scorecards.
Generated summary reports of clinical measures and required regulatory accreditation measure for administrative and clinical staff.
Conducted data retrieval, aggregation, analysis and reports.
Experience
5-7 Years
Level
Executive
Education
GED
Medical Abstractor Resume
Objective : Medical Abstractor is Contacting document source department to resolve issues with scanning or indexing of documents including physicians and their office staff. Clearly articulating and concisely interpreting hospital and department policies and procedures, HIPAA, and MGL, to callers and customers. Utilizing medical terminology and clinical information to make sound judgements and to employ problem-solving skills when processing documents for medical information.
Skills : Documentational Skills, Clinical Skills.
Description :
Provided team support for performance improvement, quality management and patient safety initiatives.
May also participated in audits of medical records, departments and patient care areas for compliance with key regulatory and accreditation requirements.
Verified accuracy of records, produce export files and identify inconsistencies in system operations and alerts appropriate staff.
Maintained all Service Level Agreements outlined in the current scope of project assignment.
Consistently met and achieved abstracting accuracy rate of 95%.
Consistently met abstracting productivity of 1.35 to 1.5 hours per case.
Worked with Registry Manager and Abstractors in modified abstracting workflow, when applicable.
Experience
2-5 Years
Level
Executive
Education
GED
Medical Abstractor Resume
Objective : Medical Abstractor is Promoting courteous and friendly interaction with patients, physicians, clinical/support staff, third parties, and other customers, internal and external to MGH. Demonstrating and maintaining excellent customer service with emphasis on being professional and courteous at all times when interacting with peers, department or Hospital management and customer.
Skills : Medical Skills, Hospital Management.
Description :
Completed weekly productivity in WorkDay or centralized productivity database on or before the deadline.
Participated in new hire and annual Quality reviews, onsite or remote.
Monitored workload assignments.
Participated in monthly conference calls and meetings, which may include presenting education topics and trends in Oncology.
Developed and maintained working relationships with project colleagues, member of medical staff and facility’s leadership as specified for each project assigned.
Interfaced with various departments to ensure that cancer-related information is available for the Cancer Registry.
Submited data as required to the State Central Registry , National Cancer Data Base, RCRS if requested by manager.
Experience
2-5 Years
Level
Executive
Education
GED
Medical Abstractor Resume
Objective : Medical Abstractor is Performing needed duties and offers assistance to peers if /when own assignments are complete. Maintaining familiarity with the various functions performed by other units of the Health Information Services Department. Referring issues and problems to the Manager as appropriate. Maintaining Confidentiality of patient information, pursuant to HIPAA, MGL, and release of information policies, at all times.
Skills : Managing, Patient Information.
Description :
Abided by the American Health Information Managements Association’s established code of ethical principles to safeguard the public and contribute within the scope of the profession to quality and efficiency in health care, thus promoting ethical conduct.
Read, in detail, the content of the medical record needed to abstract the data elements required by the Pennsylvania Health Care Cost Containment Council.
Reviewed, corrected, and resolved edits or error messages which result during the data entry process.
Participated in 3 data quality checks per year of work performance.
Assisted in researching and verifying summary data prior to PHC4 publication, as needed.
Remained abreast of changes in the PHC4 manuals.
Performed imports of demographic, laboratory, and ICD-9-CM code information into Atlas software as needed at sites utilizing the Quantros Atlas product.
Experience
2-5 Years
Level
Executive
Education
Diploma
Medical Abstractor Resume
Objective : Medical Abstractor is Analyzing and classifying documents in preparation for scanning to the document management system. Index documenting into the patient's electronic medical record (EMR) as digital formats, for ease of storage, retrieval and use. Maintaining a 99% accuracy rate and 95% productivity rate. Creating encounters in the EMR system as per policy and procedure as needed to consistently locate patient documentation.
Skills : Planning, Policy Assistant.
Description :
Know ledged of disease processes, anatomy and physiology necessary for assigning accurate codes.
Followed ICD-10 and CPT guidelines in assigning codes to visits and procedures.
Followed CMS and UCDHS teaching physician guidelines in applying evaluation and management codes.
Know ledged of Federal, State and local government regulations and requirements, which pertain to patient care information.
Know ledged of third party payor reimbursement requirements and reimbursement methodologies.
Interpreted and communicated professional fee coding information to physicians and other UCDHS staff.
Abided by all compliance principles regarding fraud and abuse in the reimbursement environment.
Experience
2-5 Years
Level
Executive
Education
Diploma
Medical Abstractor Resume
Objective : Medical Abstractor is Demonstrating a working knowledge of the HIM policies and reliable methods governing scanning and indexing. Validating the authenticity of legal documents. Utilizing advanced technology to eliminate printing and redundancy of documents.
Skills : Planning, Legal Documentation.
Description :
Reviewed, analyzed, and transcribed comprehensive, accurate data relating to patients with ocular injury, ophthalmological and optometric treatment results from various VA/DoD health applications.
Reviewed and collected data from electronic health records or other VA/DoD health applications to assist in research studies, protocols, and additional projects within the VCE.
Maintained business rules, update as necessary, and disseminate as required.
Updated and implemented quality review audit plans; ensured corrected audited inaccuracies as required. Provided quality audit result reports, recommend corrective actions, and execute corrective action plans as required.
Provided regular status reports on productivity, data quality, problems, and concerns to ensure efficient and effective performance.
Reviewed and updated procedural guides detailing specific tasks related to data abstraction.
Developed training plans outlining specific approaches, methods, schedules, tools, curricula to access VA/DoD health applications.
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