Top 12 Medical Records Specialist Skills to Put on Your Resume

Healthcare never sits still. Medical Records Specialists keep the pulse steady—guarding data, taming details, and making sure the right information lands in the right hands at the right time. A resume that blends technical knowledge, airtight organization, and people-savvy communication signals you’re ready for the work and the responsibility.

Medical Records Specialist Skills

1. ICD-10-CM
2. CPT Coding
3. HIPAA Compliance
4. EMR Systems
5. EHR Software
6. Medical Terminology
7. Data Entry
8. Health Information Systems
9. Document Management
10. Patient Privacy
11. Records Management
12. Microsoft Office

1. ICD-10-CM

ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is the standardized system for coding diagnoses and symptoms. Note the distinction: inpatient procedures are coded with ICD-10-PCS, while outpatient procedures and services are captured with CPT/HCPCS. Getting that boundary right matters.

Why It's Important

ICD-10-CM enables consistent, precise diagnosis reporting for billing, analytics, quality measures, and public health. Clean coding fuels clean data—and fewer denials.

How to Improve ICD-10-CM Skills

1. Track annual updates: New and revised codes typically take effect each October—review changes, especially guideline tweaks.

2. Practice with cases: Work through varied scenarios (acute, chronic, sequela, obstetrics, injury, external causes). Speed grows from repetition, accuracy from nuance.

3. Master guidelines: Chapter-specific rules, combination codes, laterality, and “code first”/“use additional code” notes are non-negotiable.

4. Distinguish settings: Use ICD-10-PCS for inpatient procedures and CPT/HCPCS for outpatient—no crosswires.

5. Audit yourself: Sample your work, monitor error trends, and correct patterns (missing specificity, underuse of combination codes).

6. Query when unclear: Clinical documentation improvement thrives on clear, concise queries to resolve ambiguity.

7. Use encoder tools wisely: Helpful for navigation, but always validate against official guidelines.

How to Display ICD-10-CM Skills on Your Resume

2. CPT Coding

CPT (Current Procedural Terminology) standardizes how medical, surgical, and diagnostic services are reported. It’s the language of procedures and services in outpatient and professional billing.

Why It's Important

CPT coding ties services to reimbursement and to quality reporting. Consistency avoids denials, accelerates payment, and keeps the record aligned with the care delivered.

How to Improve CPT Coding Skills

1. Study the annual code set: Category updates, bundling edits, and parenthetical notes shift every year.

2. Practice E/M rigor: Nail medical decision making and time-based rules. Get comfortable with modifiers and when not to use them.

3. Follow payer policies: National and local coverage rules, NCCI edits, and prior auth quirks can make or break claims.

4. Validate with documentation: If it isn’t documented, it didn’t happen. Verify elements support the selected code.

5. Peer review: Periodic cross-checks expose blind spots and sharpen consistency.

6. Build reference aids: Quick guides for high-volume services, common modifiers, and frequent denials save time and errors.

How to Display CPT Coding Skills on Your Resume

3. HIPAA Compliance

HIPAA sets the rules for privacy, security, and breach notification for protected health information. For medical records work, it’s the guardrail, the checklist, and the penalty box—rolled into one.

Why It's Important

HIPAA safeguards patient trust and keeps organizations clear of costly violations. It’s the backbone of lawful, ethical information handling.

How to Improve HIPAA Compliance Skills

1. Know the rules: Privacy Rule, Security Rule, Breach Notification. Understand “minimum necessary,” permitted uses, and disclosures.

2. Train regularly: Annual refreshers, role-based scenarios, phishing drills, and just-in-time reminders keep habits sharp.

3. Harden access: Role-based access, multi-factor authentication, automatic logoff, and device encryption as standard practice.

4. Monitor and audit: Review access logs and unusual activity. Investigate promptly and document remediation.

5. Have a breach playbook: Triage, risk assessment, notifications, and corrective action—timely and thorough.

6. Manage third parties: Business Associate Agreements, due diligence, and periodic reviews of vendors handling PHI.

How to Display HIPAA Compliance Skills on Your Resume

4. EMR Systems

EMR (Electronic Medical Record) systems hold a single organization’s clinical chart. Think practice- or facility-level records with documentation, orders, and results tightly woven into daily workflows.

Why It's Important

EMRs anchor accurate charting, swift retrieval, and efficient operations. Done well, they cut noise, reduce errors, and smooth handoffs.

How to Improve EMR Systems Skills

1. Streamline workflows: Customize templates, order sets, and smart phrases to match specialty and reduce clicks.

2. Clean the data: Standardize problem lists, allergies, and med histories. Curate picklists to curb junk entries.

3. Boost interoperability: Enable exchange with labs, HIEs, and referral partners. Reconcile incoming data deliberately.

4. Secure relentlessly: Enforce least-privilege access, track audit logs, and test downtime procedures.

5. Coach users: Micro-train on high-friction tasks. Quick tips beat long manuals.

How to Display EMR Systems Skills on Your Resume

5. EHR Software

EHRs (Electronic Health Records) go beyond a single site—designed for information sharing across settings, with patient portals, e-prescribing, interoperability, and decision support stitched in.

Why It's Important

EHRs improve coordination and visibility across teams and time. They connect care, speed insights, and support compliance.

How to Improve EHR Software Skills

1. Prioritize usability: Clear layouts, fewer clicks, and sensible defaults reduce errors and fatigue.

2. Advance interoperability: Use standardized vocabularies and structured data so information moves and remains meaningful.

3. Reinforce security: Patch promptly, encrypt everywhere, and align roles to real duties.

4. Leverage decision support: Alerts, order sets, and care pathways work best when tuned—trim noise, elevate signal.

5. Train, then retrain: New features land often. Short, role-specific refreshers keep adoption high.

How to Display EHR Software Skills on Your Resume

6. Medical Terminology

The shared language of anatomy, pathology, procedures, and treatments. Without it, documentation wobbles. With it, precision sings.

Why It's Important

Terminology fluency drives accurate coding, clean documentation, and crisp communication between teams.

How to Improve Medical Terminology Skills

1. Learn the building blocks: Prefixes, roots, suffixes—decode new terms on sight.

2. Use spaced repetition: Short, frequent refreshers beat cram sessions.

3. Study in context: Read actual notes, reports, and discharge summaries; tether terms to scenarios.

4. Standardize abbreviations: Follow your organization’s approved list and avoid “do-not-use” shorthand.

5. Teach to retain: Explaining a concept cements it—share tips with peers.

How to Display Medical Terminology Skills on Your Resume

7. Data Entry

The craft of entering, updating, and maintaining patient information accurately and fast—inside EHRs, registries, and internal databases.

Why It's Important

Accurate data powers care decisions, billing, reporting, and compliance. A typo can ripple far.

How to Improve Data Entry Skills

1. Design for accuracy: Use structured fields, validation rules, and smart forms; limit free text when precision is required.

2. Double-check critical fields: Patient identifiers, dates, and codes get a second look—always.

3. Standardize processes: Clear SOPs for naming, versioning, and corrections reduce guesswork.

4. Use tools: Keyboard shortcuts, text expanders, and templates save time and slash errors.

5. Automate wisely: RPA or speech recognition can help—review outputs for accuracy before finalizing.

6. Measure and improve: Track error rates and turnaround times; fix the root causes, not just the symptoms.

How to Display Data Entry Skills on Your Resume

8. Health Information Systems

Health Information Systems (HIS) knit together clinical, administrative, and financial data so information can be captured, shared, and acted upon securely.

Why It's Important

For Medical Records Specialists, HIS determines how quickly and safely data can flow—between people, departments, and organizations. It’s the infrastructure behind every chart pull and every report.

How to Improve Health Information Systems Skills

1. Champion data quality: Completeness, correctness, and standard vocabularies (like SNOMED, LOINC) keep data interoperable.

2. Support interoperability: Encourage standardized exchange and consistent reconciliation of inbound records.

3. Strengthen governance: Define data owners, access policies, retention, and change control. Write it down; follow it.

4. Train continuously: Role-based training, quick-reference guides, and refreshers after system updates.

5. Audit routinely: Validate interfaces, spot duplicate records, and correct mismatch issues in the master patient index.

6. Secure the environment: Patch schedules, backups, disaster recovery drills, and least-privilege access as standard practice.

How to Display Health Information Systems Skills on Your Resume

9. Document Management

Creating, organizing, storing, retrieving, and disposing of records—securely and systematically—across their lifecycle.

Why It's Important

Good document management means the right record surfaces quickly, stays accurate, and remains protected. Poor control invites risk.

How to Improve Document Management Skills

1. Digitize confidently: Scan with clear standards, apply OCR where appropriate, and verify readability before archiving.

2. Use an EHR/DMS playbook: Define folder structures, metadata, and versioning rules. No mystery folders.

3. Name things consistently: Standard naming conventions and indexing save hours and headaches.

4. Protect access: Encryption, role-based permissions, and audit trails guard sensitive files.

5. Audit and update: Periodic reviews, spot checks, and policy refreshes keep the system healthy.

6. Train the team: Short, task-focused sessions beat one-time lectures.

How to Display Document Management Skills on Your Resume

10. Patient Privacy

Protecting personal health information—disclosing only with consent or as the law allows. Trust is the currency; privacy is the vault.

Why It's Important

Patients share honestly when they believe their information is safe. Privacy safeguards dignity, compliance, and the care relationship itself.

How to Improve Patient Privacy Skills

1. Apply minimum necessary: Access and share only what’s needed for the task at hand.

2. Educate relentlessly: Teach proper handling of PHI, secure messaging, and workstation hygiene.

3. Encrypt and control: Protect data at rest and in transit; lock down mobile devices and removable media.

4. Monitor access: Review logs, investigate anomalies, and document actions taken.

5. Embed privacy-by-design: Bake privacy checks into new workflows, forms, and integrations from day one.

How to Display Patient Privacy Skills on Your Resume

11. Records Management

The disciplined administration of health information across acquisition, maintenance, protection, and disposition—aligned with legal, regulatory, and ethical standards.

Why It's Important

Reliable records management supports safe care, smooth retrieval, privacy protection, audits, and defensible retention.

How to Improve Records Management Skills

1. Standardize the file plan: Clear taxonomy, metadata, and indexing rules keep content findable.

2. Strengthen retention: Define schedules by record type; apply legal holds when needed; document destruction processes.

3. Move to electronic: Where appropriate, convert paper to EHR-backed workflows—traceable and searchable.

4. Audit for quality: Check completeness, timeliness, and accuracy; remediate gaps quickly.

5. Test continuity: Backups, restores, and disaster recovery drills—practice before you need it.

6. Train and measure: Role-based training plus KPIs (retrieval time, error rate) drive steady improvement.

How to Display Records Management Skills on Your Resume

12. Microsoft Office

A toolkit for everyday operations: Word for polished documentation, Excel for tracking and analysis, PowerPoint for presentations, and (where allowed) Access or SharePoint for structured data and collaboration. Use with your organization’s security controls to protect PHI—no exceptions.

Why It's Important

These tools tighten workflows, clarify reporting, and support data-driven decisions—when configured securely and used consistently.

How to Improve Microsoft Office Skills

1. Lean on templates: Standard forms and styles keep documentation consistent and fast.

2. Level up Excel: Tables, pivot tables, data validation, and conditional formatting tame large datasets.

3. Secure the files: Encrypt sensitive documents, manage permissions, and avoid local storage for PHI.

4. Connect the dots: Integrate with approved EHR exports and secure shared drives for smooth handoffs.

5. Automate tasks: Macros and quick parts reduce repetitive work—review for accuracy and security.

6. Collaborate safely: Use tracked changes, version control, and approved collaboration spaces to prevent mix-ups.

How to Display Microsoft Office Skills on Your Resume