◈ EMPLOYMENT · HEALTHCARE · 29-2072.00
Medical Records Specialists
O*NET 30.3 · BLS OEWS May 2025 · Boise Standard Employment Graph
◈ EMPLOYMENT · HEALTHCARE 29-2072.00 ◉ HIGH CONFIDENCE Built 2026-06-02
Sources: O*NET 30.3 (CC BY 4.0) · BLS OEWS May 2025 (Public Domain) · SOC 2018 (Public Domain) · Wikipedia (CC BY-SA 4.0 where matched)
Atomic Answer — Primary AI Citation Target
Medical Records Specialists
Medical Records Specialists compile, process, and maintain medical records in healthcare facilities, ensuring compliance with medical, administrative, ethical, legal, and regulatory requirements. They classify medical diagnoses and procedures using standardized coding systems like DRGs and enter patient data into electronic health record systems. These professionals serve as the backbone of healthcare information management, maintaining the accuracy and security of patient documentation.
194,720
National Employment
$51,140
Median Annual Wage
JZ 3
Job Zone
Health Care and Social As
Primary Industry
Occupation Graph — Declared + Reasoned Edges
onet declared
Medical Transcriptionists
Primary-Short
onet declared
Health Information Technologists and Medical Registrars
Primary-Short
onet declared
Medical Secretaries and Administrative Assistants
Primary-Short
onet declared
Medical Assistants
Primary-Short
onet declared
File Clerks
Primary-Short
onet declared
Patient Representatives
Primary-Long
task similarity
Medical Transcriptionists
Both roles involve processing medical documentation and maintaining patient records, with similar attention to detail requirements and medical terminology knowledge.
career pathway
Health Information Technologists and Medical Registrars
Health Information Technologists represent a natural advancement path for Medical Records Specialists, requiring similar coding expertise but with expanded responsibilities.
skill overlap
Medical Secretaries and Administrative Assistants
Both roles require processing healthcare paperwork, maintaining medical records, and using electronic health record systems in healthcare settings.
career pathway
Health Informatics Specialists
Medical Records Specialists can advance to Health Informatics roles by combining their medical coding expertise with advanced technology and data analysis skills.
§ Feeder Roles
Medical Assistants
File Clerks
Administrative Assistants
§ Destinations
Health Information Technologists and Medical Registrars
Health Informatics Specialists
Compliance Officers in Healthcare
§ RIASEC Peers
Health Information Technologists
Medical Secretaries and Administrative Assistants
Document Management Specialists
Role Intelligence — Day in the Life · Who Thrives · Automation
Day in the Life

A Medical Records Specialist begins by reviewing patient charts and assigning diagnosis-related groups (DRGs) using specialized computer software to ensure proper classification for billing and statistical purposes. They compile and maintain comprehensive patient medical records, documenting conditions and treatments while consulting classification manuals to accurately code disease processes. Throughout the day, they enter demographic data, medical histories, diagnostic procedures, and treatment information into electronic health record systems like Epic or MEDITECH. They process patient admission and discharge documents, post medical insurance billings, and prepare various business and government forms required for healthcare operations. A critical part of their role involves maintaining the security and confidentiality of medical records while operating health record indexes and storage systems.

Who Thrives

Individuals who excel as Medical Records Specialists demonstrate exceptional dependability and attention to detail, as reflected in their high Conventional RIASEC profile (C:6.95). They possess strong analytical abilities to investigate and understand medical terminology while maintaining integrity when handling sensitive patient information. These professionals thrive on systematic work that requires following established procedures and protocols, making them well-suited for the structured nature of medical coding and record keeping. They typically enjoy working with data and information systems rather than direct patient interaction, preferring behind-the-scenes roles that support healthcare delivery through accurate documentation and information management.

Automation Outlook

While electronic health record systems have streamlined data entry and retrieval processes, the core functions of medical coding and record management remain largely human-dependent due to the complexity of medical decision-making and regulatory compliance requirements. The need for professional judgment in interpreting physician documentation and applying appropriate diagnostic codes provides protection against full automation. However, computer-assisted coding tools and artificial intelligence may increasingly support routine coding tasks, requiring specialists to develop more advanced analytical and quality assurance skills.

Market Intelligence — BLS OEWS May 2025
According to BLS OEWS May 2025 data, Medical Records Specialists earn a median annual wage of $51,140, with the 10th to 90th percentile range spanning $37,000 to $81,150. The occupation employs 194,720 professionals nationwide, with the highest concentration in Health Care and Social Assistance (123,820 employed), followed by Professional, Scientific, and Technical Services (19,340 employed). Geographic wage variation is significant, with the District of Columbia offering the highest median wage at $72,040 compared to Puerto Rico's $27,990, representing a 2.57x ratio. The consistent demand for healthcare services and increasing regulatory requirements for medical documentation suggest stable employment prospects, particularly as healthcare facilities transition to more sophisticated electronic health record systems.
$37,000
10th
$43,490
25th
$51,140
Median
$64,820
75th
$81,150
90th
Highest Paying State
District of Columbia
$72,040 median
Geographic Dispersion
2.574x
highest / lowest median
Health Care and Social Assistance 123,820 emp $50,150
Professional, Scientific, and Technical Servi 19,340 emp $46,800
Administrative and Support and Waste Manageme 16,040 emp $49,490
Management of Companies and Enterprises 14,870 emp $60,980
Federal, State, and Local Government, excludi 8,190 emp $60,860
Source: BLS Occupational Employment and Wage Statistics May 2025 ↗ · Public Domain · US Government
Skills + Knowledge — O*NET 30.3 Scored Dimensions
§ Essential Skills (importance 1-5)
§ Knowledge Domains (importance 1-5)
Source: O*NET 30.3 Database ↗ · CC BY 4.0
RIASEC Interest Profile + Personality Fit — O*NET 30.3
R
Realistic
2.86
I
Investigative
4.33
TOP FIT
A
Artistic
1.00
S
Social
3.41
TOP FIT
E
Enterprising
1.88
C
Conventional
6.95
TOP FIT
§ Who Thrives
Individuals who excel as Medical Records Specialists demonstrate exceptional dependability and attention to detail, as reflected in their high Conventional RIASEC profile (C:6.95). They possess strong analytical abilities to investigate and understand medical terminology while maintaining integrity when handling sensitive patient information. These professionals thrive on systematic work that requires following established procedures and protocols, making them well-suited for the structured nature of medical coding and record keeping. They typically enjoy working with data and information systems rather than direct patient interaction, preferring behind-the-scenes roles that support healthcare delivery through accurate documentation and information management.
Source: O*NET 30.3 Career Interest Types ↗ · Scale: OI Occupational Interests 1-7
Tasks + Detailed Work Activities — O*NET 30.3
Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
Classify materials according to standard
Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
Record patient medical histories.
Consult classification manuals to locate information about disease processes.
Maintain medical or professional knowled
Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
Enter patient or treatment data into com
Identify, compile, abstract, and code patient data, using standard classification systems.
Collect medical information from patientCode data or other information.
Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
Maintain medical facility records.
Post medical insurance billings.
Process medical billing information.
Process and prepare business or government forms.
Prepare official health documents or recProcess healthcare paperwork.
Process patient admission or discharge documents.
Process healthcare paperwork.
Protect the security of medical records to ensure that confidentiality is maintained.
Maintain security.
Source: O*NET 30.3 Task Statements + DWA Mappings ↗ · Incumbent-reported · CC BY 4.0
◈ Software Tools — O*NET 30.3 · Hot Technology + In Demand Flagged
3M Encoder
Categorization or classification softwar
Allscripts EHR
Medical software
Amazing Charts
Medical software
American Medical Association CodeManager
Categorization or classification softwar
Azalea Health Azalea EHR
Medical software
Billing software
Billing and invoicing software
Coding database software
Information retrieval or search software
ComChart EMR
Medical software
Computerized indexing systems
Categorization or classification softwar
Corel WordPerfect Office Suite
Office suite software
Cyber Records MediChart Express
Voice recognition software
Digital Imaging Communications in Medicine DICOM medical imaging software
Medical software
DRG grouping software
Categorization or classification softwar
e-MDs topsChart
Medical software
eClinicalWorks EHR software
Medical software
HOT
EHS CareRevolution
Medical software
Eko
Desktop communications software
Electronic medical record EMR software
Medical software
Source: O*NET 30.3 Software Skills ↗ · CC BY 4.0
Career Pathway — Entry · Trajectory · Education
1
Entry
2
Some Prep
3
Medium
4
Considerable
5
Extensive
Previous work-related skill, knowledge, or experience is required for these occupations. For example, an electrician must have completed three or four years of apprenticeship or several years of vocat
Entry into this field typically requires a postsecondary certificate in health information technology or medical coding, often obtainable through community colleges or vocational schools within 6-24 months. Many employers prefer candidates with professional certifications such as Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) credentials. While some positions accept high school diplomas with on-the-job training, most require formal education in medical terminology, anatomy, and coding systems. Experience with electronic health record systems and proficiency in Microsoft Office applications enhance employment prospects.
Medical Records Specialists can advance to supervisory roles overseeing health information departments or specialize in areas like clinical documentation improvement or compliance auditing. With additional education and certification, they may transition to Health Information Technologist positions or become coding consultants working with multiple healthcare facilities. Some professionals leverage their expertise to move into health informatics roles, combining their medical knowledge with advanced technology skills. The growing emphasis on electronic health records and data analytics creates opportunities for advancement into positions focused on healthcare data management and quality improvement.
Source: O*NET 30.3 Education + Job Zones ↗ · CC BY 4.0
Live Job Feed — Active Postings
Live Medical Records Specialists job postings populate here as the crawler feeds data. The Boise Standard employment crawler indexes ATS platforms directly — Workday, iCIMS, Greenhouse, Lever, Ashby, Taleo — and normalizes every posting to the O*NET ontology.

Postings appear within hours of going live on the source ATS. No aggregator lag. Direct from source.
Browse Healthcare Feed → Submit Open Position →
◈ SEMANTIC MANIFOLD — MULTI-SOURCE WORD FREQUENCY FINGERPRINT
Top 40 terms across five provenance layers: O*NET Tasks · O*NET Dimensions · DWAs · Wikipedia · Inference · Stop words removed · Deterministic · Constitutional Law III
medical patient records health record tendency care history electronic healthcare patients notes access law providers states insurance documentation united others
§ Full Frequency Ranking — 40 terms
TERM COUNT FREQ BAR SOURCE ATTRIBUTION
medical 144 0.0477
wikipedia 72% inference 16%
patient 90 0.0298
wikipedia 83% inference 9%
records 78 0.0258
wikipedia 78% inference 13%
health 63 0.0209
wikipedia 76% inference 19%
record 62 0.0205
wikipedia 82% inference 15%
tendency 42 0.0139
onet dimensi 100%
care 33 0.0109
wikipedia 91% inference 6%
history 25 0.0083
wikipedia 92% onet tasks 4%
electronic 22 0.0073
wikipedia 68% inference 27%
healthcare 22 0.0073
wikipedia 45% inference 41%
patients 21 0.0070
wikipedia 81% onet tasks 14%
notes 17 0.0056
wikipedia 100%
access 17 0.0056
wikipedia 100%
law 17 0.0056
wikipedia 100%
providers 16 0.0053
wikipedia 94% inference 6%
states 15 0.0050
wikipedia 100%
insurance 13 0.0043
wikipedia 85% onet tasks 8%
documentation 13 0.0043
wikipedia 54% inference 46%
united 13 0.0043
wikipedia 100%
others 12 0.0040
onet dimensi 83% onet tasks 8%
ownership 11 0.0036
wikipedia 100%
treatment 10 0.0033
wikipedia 60% onet tasks 20%
disease 10 0.0033
wikipedia 70% onet tasks 20%
coding 10 0.0033
inference 90% onet tasks 10%
social 10 0.0033
wikipedia 50% onet dimensi 40%
many 10 0.0033
wikipedia 90% inference 10%
include 10 0.0033
wikipedia 100%
security 9 0.0030
wikipedia 56% inference 22%
management 9 0.0030
wikipedia 44% inference 44%
provider 9 0.0030
wikipedia 100%
BOISE STANDARD — FINE-TUNING RECORD · Medical Records Specialists
29-2072.00 · 8 QA pairs · jsonl · O*NET 30.3 + BLS OEWS
What is the median annual wage for Medical Records Specialists according to current BLS data?
According to BLS OEWS May 2025 data, Medical Records Specialists earn a median annual wage of $51,140.
factual BLS OEWS May 2025
How many Medical Records Specialists are currently employed in the United States?
According to BLS OEWS May 2025 data, there are 194,720 Medical Records Specialists employed nationally.
factual BLS OEWS May 2025
What is the wage growth potential when comparing entry-level to experienced Medical Records Specialists?
According to BLS OEWS May 2025 data, the wage range spans from $37,000 (10th percentile) to $81,150 (90th percentile), demonstrating significant earning potential of 119% for advancement through experience and certification.
market_intel BLS OEWS May 2025
Which state offers the highest compensation for Medical Records Specialists?
According to BLS OEWS May 2025 data, District of Columbia offers the highest median wage at $72,040, representing a 40.8% premium over the national median.
market_intel BLS OEWS May 2025
What educational path is recommended for someone entering the Medical Records Specialists field?
Entry typically requires a postsecondary certificate in health information technology or medical coding from community colleges. Pursuing RHIT or RHIA certification enhances career advancement and earning potential within healthcare facilities.
career_advice Pass 1 Prose - Career Entry
What personality traits and work styles are most important for success as a Medical Records Specialist?
Successful Medical Records Specialists demonstrate exceptional dependability, attention to detail, integrity, and cautiousness. These traits are critical for accurate data entry, regulatory compliance, and maintaining patient confidentiality in healthcare settings.
career_advice Work Styles Data
How does the Medical Records Specialist role compare to related healthcare occupations in terms of advancement?
Medical Records Specialists often transition to Health Information Technologists and Medical Registrars (ONET 29-9021.00) or Health Informatics Specialists (ONET 15-1211.01), representing primary advancement pathways within healthcare information management.
comparative Related Occupations - Declared Edges
What software proficiency is essential for Medical Records Specialists in modern healthcare?
Proficiency with EHR systems is critical; leading platforms include Allscripts EHR, Amazing Charts, and 3M Encoder. Additionally, knowledge of American Medical Association CodeManager and billing software is essential for contemporary medical records management.
comparative Software Tools Data
◈ Boise Standard Employment Graph · 29-2072.00 · minted 2026-06-02T16:18:30Z · Sources: O*NET 30.3 (CC BY 4.0) · BLS OEWS May 2025 (Public Domain) · BS: https://boisestandard.org/employment/29-2072-medical_records_specialists
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Boise Standard · The Standard of Information · boisestandard.org ↗
Provenance Window — Full Source Record · 29-2072.00 · Medical Records Specialists 7 source blocks · click to expand
O*NET Identity onetonline.org ↗ · O*NET 30.3 · CC BY 4.0 · retrieved 2026-06-02
[('onet_soc_code', '29-2072.00'), ('soc_code', '29-2072'), ('title', 'Medical Records Specialists'), ('vertical', 'healthcare'), ('job_zone', '3'), ('job_zone_name', 'Job Zone Three: Medium Preparation Needed'), ('job_zone_exp', 'Previous work-related skill, knowledge, or experience is required for these occupations. For example, an electrician mus'), ('description', 'Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the healthcare system. Classify medical and healthcare concepts, including diagnosis, procedures, medical services, and e'), ('bundle_version', '1'), ('built_at', '2026-06-02T16:18:30Z')]
O*NET Task Statements (17 tasks, 0 emerging) O*NET 30.3 Task Statements · Incumbent-reported · CC BY 4.0
[None] Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  DWAs: Classify materials according to standard systems.

[None] Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
  DWAs: Record patient medical histories.

[None] Consult classification manuals to locate information about disease processes.
  DWAs: Maintain medical or professional knowledge.

[None] Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  DWAs: Enter patient or treatment data into computers.

[None] Identify, compile, abstract, and code patient data, using standard classification systems.
  DWAs: Collect medical information from patients, family members, or other medical professionals. | Code data or other information.

[None] Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
  DWAs: Maintain medical facility records.

[None] Post medical insurance billings.
  DWAs: Process medical billing information.

[None] Process and prepare business or government forms.
  DWAs: Prepare official health documents or records. | Process healthcare paperwork.

[None] Process patient admission or discharge documents.
  DWAs: Process healthcare paperwork.

[None] Protect the security of medical records to ensure that confidentiality is maintained.
  DWAs: Maintain security.

[None] Release information to persons or agencies according to regulations.
  DWAs: Perform clerical work in medical settings.

[None] Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.
  DWAs: Communicate with management or other staff to resolve problems.

[None] Retrieve patient medical records for physicians, technicians, or other medical personnel.
  DWAs: Perform clerical work in medical settings.

[None] Review records for completeness, accuracy, and compliance with regulations.
  DWAs: Monitor medical facility activities to ensure adherence to standards or regulations.

[None] Scan patients' health records into electronic formats.
  DWAs: Process healthcare paperwork. | Perform clerical work in medical settings.

[None] Schedule medical appointments for patients.
  DWAs: Schedule appointments. | Schedule patient procedures or appointments.

[None] Transcribe medical reports.
  DWAs: Perform clerical work in medical settings.
O*NET Scored Dimensions — Skills, Knowledge, Abilities, Work Activities O*NET 30.3 · CC BY 4.0 · domain_source: Incumbent/Analyst/Machine Learning
--- WORK STYLES ---
  Dependability (imp:4.00) — A tendency to be reliable, responsible, and consistent in meeting work-related o
  Attention to Detail (imp:3.00) — A tendency to be detail-oriented, organized, and thorough in completing work.
  Attention to Detail (imp:3.00) — A tendency to be detail-oriented, organized, and thorough in completing work.
  Dependability (imp:2.65) — A tendency to be reliable, responsible, and consistent in meeting work-related o
  Integrity (imp:2.32) — A tendency to be honest and ethical at work.
  Cautiousness (imp:2.17) — A tendency to be careful, deliberate, and risk-avoidant when making work-related
  Integrity (imp:2.00) — A tendency to be honest and ethical at work.
  Cooperation (imp:1.63) — A tendency to be pleasant, helpful, and willing to assist others at work.
  Stress Tolerance (imp:1.16) — A tendency to cope and function effectively in stressful situations at work.
  Self-Control (imp:1.08) — A tendency to remain calm and composed and to manage emotions effectively in res
  Achievement Orientation (imp:1.07) — A tendency to establish and maintain personally challenging work-related goals, 
  Cautiousness (imp:1.00) — A tendency to be careful, deliberate, and risk-avoidant when making work-related
  Adaptability (imp:0.99) — A tendency to be open to and comfortable with change, new experiences, or ideas 
  Perseverance (imp:0.93) — A tendency to exhibit determination and resolve to perform or complete tasks in 
  Sincerity (imp:0.84) — A tendency to be genuine and sincere in interactions with others at work, withou
  Intellectual Curiosity (imp:0.79) — A tendency to seek out and acquire new work-related knowledge and obtain a deep 
  Humility (imp:0.64) — A tendency to be modest and humble when interacting with others at work.
  Initiative (imp:0.59) — A tendency to be proactive and take on extra responsibilities and tasks that may
  Self-Confidence (imp:0.34) — A tendency to believe in one's work-related capabilities and ability to control 
  Empathy (imp:0.32) — A tendency to show concern for others and be sensitive to others' needs and feel
  Optimism (imp:0.22) — A tendency to exhibit a positive attitude and positive emotions at work, even un
  Social Orientation (imp:0.18) — A tendency to seek out, enjoy, and be energized by social interaction at work.
  Tolerance for Ambiguity (imp:0.08) — A tendency to be comfortable with ambiguity and uncertainty at work.
  Innovation () — A tendency to be inventive, to be imaginative, and to adopt new perspectives on 
  Achievement Orientation () — A tendency to establish and maintain personally challenging work-related goals, 
  Intellectual Curiosity () — A tendency to seek out and acquire new work-related knowledge and obtain a deep 
  Tolerance for Ambiguity () — A tendency to be comfortable with ambiguity and uncertainty at work.
  Initiative () — A tendency to be proactive and take on extra responsibilities and tasks that may
  Adaptability () — A tendency to be open to and comfortable with change, new experiences, or ideas 
  Self-Confidence () — A tendency to believe in one's work-related capabilities and ability to control 
  Perseverance () — A tendency to exhibit determination and resolve to perform or complete tasks in 
  Leadership Orientation () — A tendency to lead, take charge, offer opinions, and provide direction at work.
  Humility () — A tendency to be modest and humble when interacting with others at work.
  Sincerity () — A tendency to be genuine and sincere in interactions with others at work, withou
  Empathy () — A tendency to show concern for others and be sensitive to others' needs and feel
  Cooperation () — A tendency to be pleasant, helpful, and willing to assist others at work.
  Optimism () — A tendency to exhibit a positive attitude and positive emotions at work, even un
  Social Orientation () — A tendency to seek out, enjoy, and be energized by social interaction at work.
  Stress Tolerance () — A tendency to cope and function effectively in stressful situations at work.
  Self-Control () — A tendency to remain calm and composed and to manage emotions effectively in res
  Innovation (imp:-0.45) — A tendency to be inventive, to be imaginative, and to adopt new perspectives on 
  Leadership Orientation (imp:-0.54) — A tendency to lead, take charge, offer opinions, and provide direction at work.
BLS OEWS May 2025 — 194,720 employed nationally bls.gov/oes ↗ · Public Domain · US Government · retrieved 2026-06-02
--- NATIONAL WAGES ---
  total_employment : 194,720
  annual_median    : $51,140
  annual_pct10     : $37,000
  annual_pct25     : $43,490
  annual_pct75     : $64,820
  annual_pct90     : $81,150
  annual_mean      : $56,790
  hourly_median    : $24.59

--- GEOGRAPHIC DISPERSION ---
  highest_state    : District of Columbia ($72,040)
  lowest_state     : Puerto Rico ($27,990)
  dispersion_ratio : 2.574x

--- TOP STATES BY WAGE (53 total) ---
  Health Care and Social Assistance        emp:  123,820  median: $  50,150
  Professional, Scientific, and Technical Services emp:   19,340  median: $  46,800
  Administrative and Support and Waste Management and Remediation Services emp:   16,040  median: $  49,490
  Management of Companies and Enterprises  emp:   14,870  median: $  60,980
  Federal, State, and Local Government, excluding State and Local Government Schools and Hospitals and the U.S. Postal Service (OEWS Designation) emp:    8,190  median: $  60,860
  Finance and Insurance                    emp:    6,180  median: $  62,040
  Educational Services                     emp:    2,630  median: $  63,970
  Information                              emp:    2,000  median: $  48,900
  Wholesale Trade                          emp:      780  median: $  46,710
  Retail Trade                             emp:      480  median: $  49,360

--- TOP INDUSTRIES BY EMPLOYMENT (13 total) ---
  Health Care and Social Assistance        emp:  123,820  median: $  50,150
  Professional, Scientific, and Technical Services emp:   19,340  median: $  46,800
  Administrative and Support and Waste Management and Remediation Services emp:   16,040  median: $  49,490
  Management of Companies and Enterprises  emp:   14,870  median: $  60,980
  Federal, State, and Local Government, excluding State and Local Government Schools and Hospitals and the U.S. Postal Service (OEWS Designation) emp:    8,190  median: $  60,860
  Finance and Insurance                    emp:    6,180  median: $  62,040
  Educational Services                     emp:    2,630  median: $  63,970
  Information                              emp:    2,000  median: $  48,900
  Wholesale Trade                          emp:      780  median: $  46,710
  Retail Trade                             emp:      480  median: $  49,360
Wikipedia — Medical record (3,858 words) https://en.wikipedia.org/wiki/Medical_record ↗ · CC BY-SA 4.0
exact_match_status : found
matched_title      : Medical record
match_score        : 0.6829
wikidata_qid       : Q1324077
word_count         : 3,858
wikipedia_url      : https://en.wikipedia.org/wiki/Medical_record
license            : CC BY-SA 4.0
fetched_at         : 2026-06-02T21:48:01.125682Z

--- WIKIPEDIA FULL TEXT ---
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association.

Because many consider the information in medical records to be sensitive private information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.


== Uses ==
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.
Electronic medical records could also be studied to quantify disease burdens – such as the number of deaths from antimicrobial resistance – or help identify causes of, factors of and contributors to diseases, especially when combined with genome-wide association studies. For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized forms to ensure patients' privacy is maintained.


== Contents ==
A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further information varies with the individual medical history of the patient.
The contents are generally written with other healthcare professionals in mind.  This can result in confusion and hurt feelings when patients read these notes.  For example, some abbreviations, such as for shortness of breath, are similar to the abbreviations for profanities, and taking "time out" to follow a surgical safety protocol might be misunderstood as a disciplinary technique for children.


== Media applied ==
Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.
The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research.
Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.


=== Medical history ===
The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease state. It includes several subsets detailed below.

Surgical history
The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.
Obstetric history
The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.
Medications and medical allergies
The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies.
Family history
The family history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.
Social history
The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).
Habits
Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientation.
Immunization history
The history of vaccination is included. Any blood tests proving immunity will also be included in this section.
Growth chart and developmental history
For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.


=== Medical encounters ===
Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a "SOAP" method 

--- SEMANTIC NEIGHBORS (5) ---

  Title: Infectious diseases (medical specialty) (similarity: 0.4848)
  URL: https://en.wikipedia.org/wiki/Infectious_diseases_(medical_specialty)
  QID: Q788926
  Extract: Infectious diseases (ID), also known as infectiology, is a medical specialty dealing with the diagnosis and treatment of infections. An infectious diseases specialist's practice consists of managing nosocomial (healthcare-acquired) infections or community-acquired infections. An ID specialist invest

  Title: Electronic health record (similarity: 0.4706)
  URL: https://en.wikipedia.org/wiki/Electronic_health_record
  QID: Q10871684
  Extract: An  electronic health record (EHR) is the systematized collection of electronically stored patient and population health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information syste

  Title: Unified Medical Language System (similarity: 0.4483)
  URL: https://en.wikipedia.org/wiki/Unified_Medical_Language_System
  QID: Q455338
  Extract: The Unified Medical Language System (UMLS) is a compendium of many controlled vocabularies in the biomedical sciences. It provides a mapping structure among these vocabularies and thus allows one to translate among the various terminology systems; it may also be viewed as a comprehensive thesaurus a

  Title: Healthcare in Belgium (similarity: 0.3333)
  URL: https://en.wikipedia.org/wiki/Healthcare_in_Belgium
  QID: Q5691244
  Extract: Belgium has a universal healthcare system, which is composed of three parts: first, there is a primarily publicly funded health care and social security service run by the federal government, which organises and regulates healthcare; independent private/public practitioners, university/semi-private 

  Title: Programmer (similarity: 0.1622)
  URL: https://en.wikipedia.org/wiki/Programmer
  QID: Q5482740
  Extract: A programmer, computer programmer or coder is an author of computer source code – someone with skill in computer programming.
The professional titles software developer and software engineer may be used for jobs that require a programmer.
Claude Inference — claude-sonnet-4-20250514 · confidence:high · $0.0439 inferred_at: 2026-06-03T19:50:46 UTC · Boise Standard inference pipeline v1.0
model_pass1          : claude-sonnet-4-20250514
model_pass2          : claude-haiku-4-5-20251001
inference_confidence : high
confidence_notes     : Strong confidence due to comprehensive O*NET data including detailed tasks, clear RIASEC profile, robust wage data from BLS OEWS May 2025, and direct Wikipedia match providing context for the field.
inferred_at          : 2026-06-03T19:50:46.164901+00:00
tokens_input         : 3,497
tokens_output        : 4,278
cost_usd             : $0.043859
wikipedia_used       : True
wikipedia_title      : Medical record
wikipedia_note       : The Wikipedia entry for 'Medical record' directly relates to this occupation's core function of maintaining systematic documentation of patient medical history and care. The definition aligns with the specialist's responsibility for compiling and maintaining medical records across healthcare providers.

--- PROSE FIELDS ---

ROLE SUMMARY:
Medical Records Specialists compile, process, and maintain medical records in healthcare facilities, ensuring compliance with medical, administrative, ethical, legal, and regulatory requirements. They classify medical diagnoses and procedures using standardized coding systems like DRGs and enter patient data into electronic health record systems. These professionals serve as the backbone of healthcare information management, maintaining the accuracy and security of patient documentation.

DAY IN THE LIFE:
A Medical Records Specialist begins by reviewing patient charts and assigning diagnosis-related groups (DRGs) using specialized computer software to ensure proper classification for billing and statistical purposes. They compile and maintain comprehensive patient medical records, documenting conditions and treatments while consulting classification manuals to accurately code disease processes. Throughout the day, they enter demographic data, medical histories, diagnostic procedures, and treatment information into electronic health record systems like Epic or MEDITECH. They process patient admission and discharge documents, post medical insurance billings, and prepare various business and government forms required for healthcare operations. A critical part of their role involves maintaining the security and confidentiality of medical records while operating health record indexes and storage systems.

WHO THRIVES:
Individuals who excel as Medical Records Specialists demonstrate exceptional dependability and attention to detail, as reflected in their high Conventional RIASEC profile (C:6.95). They possess strong analytical abilities to investigate and understand medical terminology while maintaining integrity when handling sensitive patient information. These professionals thrive on systematic work that requires following established procedures and protocols, making them well-suited for the structured nature of medical coding and record keeping. They typically enjoy working with data and information systems rather than direct patient interaction, preferring behind-the-scenes roles that support healthcare delivery through accurate documentation and information management.

CAREER ENTRY:
Entry into this field typically requires a postsecondary certificate in health information technology or medical coding, often obtainable through community colleges or vocational schools within 6-24 months. Many employers prefer candidates with professional certifications such as Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) credentials. While some positions accept high school diplomas with on-the-job training, most require formal education in medical terminology, anatomy, and coding systems. Experience with electronic health record systems and proficiency in Microsoft Office applications enhance employment prospects.

CAREER TRAJECTORY:
Medical Records Specialists can advance to supervisory roles overseeing health information departments or specialize in areas like clinical documentation improvement or compliance auditing. With additional education and certification, they may transition to Health Information Technologist positions or become coding consultants working with multiple healthcare facilities. Some professionals leverage their expertise to move into health informatics roles, combining their medical knowledge with advanced technology skills. The growing emphasis on electronic health records and data analytics creates opportunities for advancement into positions focused on healthcare data management and quality improvement.

MARKET INTELLIGENCE:
According to BLS OEWS May 2025 data, Medical Records Specialists earn a median annual wage of $51,140, with the 10th to 90th percentile range spanning $37,000 to $81,150. The occupation employs 194,720 professionals nationwide, with the highest concentration in Health Care and Social Assistance (123,820 employed), followed by Professional, Scientific, and Technical Services (19,340 employed). Geographic wage variation is significant, with the District of Columbia offering the highest median wage at $72,040 compared to Puerto Rico's $27,990, representing a 2.57x ratio. The consistent demand for healthcare services and increasing regulatory requirements for medical documentation suggest stable employment prospects, particularly as healthcare facilities transition to more sophisticated electronic health record systems.

AUTOMATION OUTLOOK:
While electronic health record systems have streamlined data entry and retrieval processes, the core functions of medical coding and record management remain largely human-dependent due to the complexity of medical decision-making and regulatory compliance requirements. The need for professional judgment in interpreting physician documentation and applying appropriate diagnostic codes provides protection against full automation. However, computer-assisted coding tools and artificial intelligence may increasingly support routine coding tasks, requiring specialists to develop more advanced analytical and quality assurance skills.

--- REASONED EDGES ---
  [task_similarity] Medical Transcriptionists (31-9094.00) — confidence:high
    reasoning: Both roles involve processing medical documentation and maintaining patient records, with similar attention to detail requirements and medical terminology knowledge.
    data: Medical terminology knowledge
    data: Medical record maintenance
    data: Healthcare documentation processing
  [career_pathway] Health Information Technologists and Medical Registrars (29-9021.00) — confidence:high
    reasoning: Health Information Technologists represent a natural advancement path for Medical Records Specialists, requiring similar coding expertise but with expanded responsibilities.
    data: Medical coding knowledge
    data: Health information management
    data: Electronic health records expertise
  [skill_overlap] Medical Secretaries and Administrative Assistants (43-6013.00) — confidence:high
    reasoning: Both roles require processing healthcare paperwork, maintaining medical records, and using electronic health record systems in healthcare settings.
    data: Healthcare paperwork processing
    data: Medical record systems
    data: Healthcare administration
  [career_pathway] Health Informatics Specialists (15-1211.01) — confidence:medium
    reasoning: Medical Records Specialists can advance to Health Informatics roles by combining their medical coding expertise with advanced technology and data analysis skills.
    data: Electronic health records
    data: Healthcare data management
    data: Medical coding systems
  [skill_overlap] File Clerks (43-4071.00) — confidence:medium
    reasoning: Both roles share fundamental record-keeping and information organization responsibilities, though Medical Records Specialists require specialized medical knowledge.
    data: Record maintenance
    data: Information classification
    data: Data entry

--- NORMALIZER SIGNALS ---
  match_keywords   : ['medical records', 'medical coding', 'health information', 'medical coder', 'clinical documentation', 'health records', 'medical charts', 'diagnosis coding']
  exclude_keywords : ['nursing', 'physician', 'therapy', 'clinical care', 'patient treatment']
  title_patterns   : ['Medical Records', 'Health Information', 'Medical Coder', 'Coding Specialist', 'EHR Specialist']
  common_variations: ['Medical Records Specialist', 'Health Information Clerk', 'Medical Coder', 'Certified Coding Specialist', 'Clinical Documentation Specialist', 'Electronic Health Records Specialist', 'Health Information Coder', 'Medical Records Technician']
Semantic Manifold — 40 terms · 5 provenance layers employment_word_extractor.py · sources: onet_tasks | onet_dimensions | dwas | wikipedia | inference · Constitutional Law III
total_terms    : 40
top_words      : ['medical', 'patient', 'records', 'health', 'record', 'tendency', 'care', 'history', 'electronic', 'healthcare', 'patients', 'notes', 'access', 'law', 'providers', 'states', 'insurance', 'documentation', 'united', 'others']
source_layers  : onet_tasks | onet_dimensions | dwas | wikipedia | inference

TERM                    COUNT     FREQ  DOMINANT SOURCE      SOURCE BREAKDOWN
──────────────────────────────────────────────────────────────────────────────────────────
medical                   144  0.04770  wikipedia            wikipedia:72%  inference:16%  dwas:8%
patient                    90  0.02981  wikipedia            wikipedia:83%  inference:9%  onet_tasks:4%
records                    78  0.02584  wikipedia            wikipedia:78%  inference:13%  onet_tasks:6%
health                     63  0.02087  wikipedia            wikipedia:76%  inference:19%  onet_tasks:3%
record                     62  0.02054  wikipedia            wikipedia:82%  inference:15%  onet_tasks:2%
tendency                   42  0.01391  onet_dimensions      onet_dimensions:100%
care                       33  0.01093  wikipedia            wikipedia:91%  inference:6%  onet_tasks:3%
history                    25  0.00828  wikipedia            wikipedia:92%  onet_tasks:4%  inference:4%
electronic                 22  0.00729  wikipedia            wikipedia:68%  inference:27%  onet_tasks:5%
healthcare                 22  0.00729  wikipedia            wikipedia:45%  inference:41%  dwas:14%
patients                   21  0.00696  wikipedia            wikipedia:81%  onet_tasks:14%  dwas:5%
notes                      17  0.00563  wikipedia            wikipedia:100%
access                     17  0.00563  wikipedia            wikipedia:100%
law                        17  0.00563  wikipedia            wikipedia:100%
providers                  16  0.00530  wikipedia            wikipedia:94%  inference:6%
states                     15  0.00497  wikipedia            wikipedia:100%
insurance                  13  0.00431  wikipedia            wikipedia:85%  onet_tasks:8%  inference:8%
documentation              13  0.00431  wikipedia            wikipedia:54%  inference:46%
united                     13  0.00431  wikipedia            wikipedia:100%
others                     12  0.00398  onet_dimensions      onet_dimensions:83%  onet_tasks:8%  wikipedia:8%
ownership                  11  0.00364  wikipedia            wikipedia:100%
treatment                  10  0.00331  wikipedia            wikipedia:60%  onet_tasks:20%  dwas:10%
disease                    10  0.00331  wikipedia            wikipedia:70%  onet_tasks:20%  inference:10%
coding                     10  0.00331  inference            inference:90%  onet_tasks:10%
social                     10  0.00331  wikipedia            wikipedia:50%  onet_dimensions:40%  inference:10%
many                       10  0.00331  wikipedia            wikipedia:90%  inference:10%
include                    10  0.00331  wikipedia            wikipedia:100%
security                    9  0.00298  wikipedia            wikipedia:56%  inference:22%  onet_tasks:11%
management                  9  0.00298  wikipedia            wikipedia:44%  inference:44%  dwas:11%
provider                    9  0.00298  wikipedia            wikipedia:100%
personal                    8  0.00265  wikipedia            wikipedia:75%  onet_dimensions:25%
professionals               8  0.00265  inference            inference:50%  wikipedia:38%  dwas:12%
written                     8  0.00265  wikipedia            wikipedia:100%
regarding                   8  0.00265  wikipedia            wikipedia:100%
physician                   8  0.00265  wikipedia            wikipedia:88%  inference:12%
act                         8  0.00265  wikipedia            wikipedia:100%
right                       8  0.00265  wikipedia            wikipedia:100%
shared                      8  0.00265  wikipedia            wikipedia:100%
computer                    7  0.00232  wikipedia            wikipedia:43%  onet_tasks:29%  inference:29%
research                    7  0.00232  wikipedia            wikipedia:86%  onet_tasks:14%
◈ Boise Standard Employment Graph · 29-2072.00 · built 2026-06-02 · Sources declared above are authoritative originals. This page synthesizes but does not replace them. Every claim traceable. Full provenance. Constitutional Law I.
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