Top 12 Medical Records Technician Skills to Put on Your Resume
In today’s fast-moving healthcare world, Medical Records Technicians carry the spine of clinical data. Strong skills mean cleaner charts, fewer denials, faster retrieval, and safer patient information. You keep the engine purring—and the details airtight.
Medical Records Technician Skills
- ICD-10-CM
- CPT Coding
- HIPAA Compliance
- EHR Systems
- EMR Software
- Medical Terminology
- Health Informatics
- Data Entry
- Document Scanning
- Patient Confidentiality
- Records Management
- Quality Assurance
1. ICD-10-CM
ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is the standardized system for coding diagnoses, signs and symptoms, conditions, and external causes of injury. It supports clinical documentation, reporting, analytics, and reimbursement. Note: ICD-10-CM does not code procedures; inpatient procedures use ICD-10-PCS, and outpatient procedures/services are coded with CPT/HCPCS.
Why It's Important
Accurate ICD-10-CM coding drives correct reimbursement, quality reporting, population health analysis, and risk adjustment. Consistency here reduces denials and sharpens the clinical story.
How to Improve ICD-10-CM Skills
Track annual updates: ICD-10-CM guidelines and codes update each year (effective October 1). Review changes and apply them promptly.
Master the Official Guidelines: Work directly from the ICD-10-CM Official Guidelines for Coding and Reporting; keep the latest version handy.
Study authoritative guidance: Use Coding Clinic (AHA) and organizational policies to resolve gray areas and edge cases.
Practice with real scenarios: Code de-identified cases; compare results with peers or auditors and reconcile differences.
Audit yourself: Run periodic self-audits focused on common error types (laterality, combination codes, sequencing).
Strengthen documentation queries: Write clear, compliant queries that close specificity gaps without leading the provider.
Steady practice plus guideline fluency—your accuracy and speed climb together.
How to Display ICD-10-CM Skills on Your Resume
2. CPT Coding
CPT (Current Procedural Terminology) codes describe medical, surgical, and diagnostic services for reporting and billing, primarily in outpatient and professional settings. Maintained by the AMA, updates take effect January 1 each year.
Why It's Important
Reliable CPT coding ensures clean claims, accurate reimbursement, and clear communication of services delivered. It ties tightly to medical necessity and documentation quality.
How to Improve CPT Coding Skills
Know the structure: Categories I–III, modifiers, parenthetical notes, and section-specific rules—read the codebook front matter and guidelines.
Sync with annual changes: New, revised, and deleted codes arrive each January; adjust templates and workflows accordingly.
Practice bundling logic: Understand NCCI edits, modifier usage (e.g., 25, 59, X modifiers), and when services are separately reportable.
Pair CPT with documentation: Trace each code to a specific, supportable note element; flag gaps early with concise queries.
Use case reviews: Work mixed-level scenarios; calibrate with peers and supervisors to align interpretations.
Stay connected: Engage with professional communities (AHIMA, AAPC) for updates, tips, and tricky case discussions.
Good CPT coding turns documentation into a clean, defensible claim.
How to Display CPT Coding Skills on Your Resume
3. HIPAA Compliance
HIPAA compliance means safeguarding protected health information (PHI) across privacy, security, and breach notification requirements. It spans policies, training, access controls, risk analysis, and incident response.
Why It's Important
Trust hinges on privacy. Compliance protects patients, reduces organizational risk, and aligns daily record handling with federal law and ethics.
How to Improve HIPAA Compliance Skills
Know the rules: Privacy Rule, Security Rule, Breach Notification Rule—understand minimum necessary, permissible disclosures, and safeguards.
Train relentlessly: Short refreshers, scenario drills, phishing simulations. Keep logs of completion and competency.
Risk analysis and mitigation: Identify threats, evaluate likelihood/impact, document remediation, and re-assess regularly.
Tighten access: Role-based access, unique IDs, strong authentication, automatic logoff, and routine audit log reviews.
Encrypt and protect: Encryption in transit and at rest, secure messaging, device management, and media controls.
Vendor vigilance: Business associate agreements, security due diligence, and ongoing oversight.
Incident-ready: Clear breach response plan, timelines, documentation, and patient notification processes.
Culture plus controls—both are non-negotiable.
How to Display HIPAA Compliance Skills on Your Resume
4. EHR Systems
EHR systems are digital platforms housing patient histories, orders, results, and documentation—supporting care coordination, billing, analytics, and compliance.
Why It's Important
EHRs centralize information, shrink turnaround times, and boost data quality. When configured well, they tame chaos and surface what matters at the point of care.
How to Improve EHR Systems Skills
Usability first: Streamline templates, reduce clicks, and align fields with real workflows; remove dead weight data.
Interoperability: Embrace standards (HL7, FHIR) and shared data classes (e.g., USCDI) to improve cross-system exchange.
Training that sticks: Role-based training, quick-reference guides, and tip sheets tied to recent build changes.
Data quality: Validation rules, smart forms, required fields, and periodic chart audits to curb duplicates and errors.
Security posture: Least-privilege access, MFA, patching cadence, and periodic technical safeguard reviews.
Feedback loop: Collect user feedback, prioritize fixes, measure impact, and iterate.
Small configuration tweaks can unlock big gains in speed and accuracy.
How to Display EHR Systems Skills on Your Resume
5. EMR Software
EMR software focuses on a single practice’s digital chart—encounters, medications, problem lists, and progress notes. Think of it as the clinic’s day-to-day documentation hub.
Why It's Important
It speeds documentation, reduces errors, and standardizes recordkeeping. Better EMR use equals clearer notes and swifter retrieval.
How to Improve EMR Software Skills
Simplify the screen: Clean layouts, logical tab order, and minimal redundant fields. Reduce cognitive drag.
Build smart templates: Role-specific templates, quick-text, macros, and defaults that respect compliance and medical necessity.
Interoperability mindset: Map codes and vocabularies so data can flow (e.g., LOINC, SNOMED CT, RxNorm where applicable).
Privacy and security: Access controls, encryption, audit logs, and device protections baked into daily use.
Hands-on training: Short, scenario-based sessions; sandbox practice; targeted refreshers after upgrades.
Make the software work for the workflow, not the other way around.
How to Display EMR Software Skills on Your Resume
6. Medical Terminology
The shared language of medicine—roots, prefixes, suffixes, and abbreviations—keeps documentation precise and unambiguous across teams and settings.
Why It's Important
Fluency in terminology sharpens coding, speeds data entry, and prevents misinterpretation. Clarity in, clarity out.
How to Improve Medical Terminology Skills
Learn the building blocks: Word roots, prefixes, suffixes; decode unfamiliar terms on the fly.
Spaced repetition: Flashcards and micro-quizzes to lock in high-frequency terms.
Read real notes: Discharge summaries, imaging reports, operative notes—absorb context and usage.
Curate a style list: Standard abbreviations, do-not-use lists, and organization-specific conventions.
Teach back: Explain terms to a peer; if you can teach it, you own it.
Repetition and context make the vocabulary stick.
How to Display Medical Terminology Skills on Your Resume
7. Health Informatics
Health Informatics blends clinical practice, data standards, and information systems to turn raw health data into meaningful, actionable information.
Why It's Important
It fuels safer care, better analytics, and leaner operations. Good informatics turns records into insight.
How to Improve Health Informatics Skills
Data quality rigor: Validation rules, required fields, and routine data profiling to catch errors early.
System integration: Support clean interfaces and master data management to reduce duplicates and fragmentation.
Interoperability standards: Understand HL7, FHIR, and code sets (SNOMED CT, LOINC, RxNorm) used across systems.
Privacy and security: Align workflows with HIPAA and cybersecurity practices; document controls and monitoring.
Governance: Participate in data stewardship, change control, and policy updates; measure impact with KPIs.
The right standards plus disciplined processes—data becomes dependable.
How to Display Health Informatics Skills on Your Resume
8. Data Entry
Data entry is the timely, accurate capture of patient and encounter information into EHRs and related systems—clean inputs that power every downstream process.
Why It's Important
Precise entry reduces rework, avoids denials, and strengthens clinical and operational reporting. Sloppy inputs ripple everywhere.
How to Improve Data Entry Skills
Touch typing: Increase speed and accuracy; practice daily and test yourself monthly.
Shortcut fluency: Learn system hotkeys, text expanders, and navigation tricks to shave seconds each step.
Terminology comfort: The better you know the terms, the fewer errors and hesitations.
Standardized templates: Use structured fields and validated forms to prevent incomplete entries.
Double-check rhythm: Quick reviews on critical fields (DOB, MRN, modifiers, dates of service) before finalizing.
Ergonomics and focus: Reduce fatigue with good posture, lighting, and focused blocks of time.
Small habits compound into big accuracy gains.
How to Display Data Entry Skills on Your Resume
9. Document Scanning
Document scanning converts paper charts and incoming paperwork into indexed, searchable digital files that slot cleanly into the patient record.
Why It's Important
It speeds access, preserves legibility, and protects against loss. Done right, it strengthens compliance and continuity of care.
How to Improve Document Scanning Skills
Right equipment: Reliable scanners with automatic document feeders, duplex capability, and sufficient DPI.
Prep before scan: Remove staples, flatten folds, sort by type; fewer jams, better images.
Optimal settings: 300 DPI for text, higher for images; grayscale for clarity, color when clinically relevant; use PDF/A for long-term archiving.
OCR and indexing: Enable OCR for searchability; index by patient ID, date, and document type with a consistent naming convention.
Quality checks: Spot-check every batch for completeness, orientation, and readability; rescan as needed.
Secure storage: Store in encrypted, access-controlled systems; ensure a signed Business Associate Agreement and documented safeguards with any cloud vendor.
Retention and disposal: Follow retention schedules and use secure destruction methods; track destruction certificates.
Orderly intake today saves hours of hunting tomorrow.
How to Display Document Scanning Skills on Your Resume
10. Patient Confidentiality
Patient confidentiality is the ethical and legal duty to protect PHI from improper access, use, or disclosure—across paper, digital, and verbal channels.
Why It's Important
Privacy builds trust. It also meets legal requirements and shields patients from harm or embarrassment.
How to Improve Patient Confidentiality Skills
Minimum necessary: Access only what’s needed to do the job. No curiosity lookups, ever.
Secure screens and spaces: Lock workstations, use privacy filters, and keep paper files out of sight.
Controlled sharing: Verify identity, confirm permissions, and log disclosures appropriately.
De-identify when possible: Use de-identified data for training and testing.
Safe disposal: Shred paper and securely wipe media; document destruction.
Continuous awareness: Short reminders, spot checks, and prompt reporting of any suspected incident.
Protecting privacy is everyone’s everyday job.
How to Display Patient Confidentiality Skills on Your Resume
11. Records Management
Records Management governs the lifecycle of the medical record—creation, maintenance, access, retention, and final disposition—while preserving accuracy, integrity, and compliance.
Why It's Important
Strong controls prevent gaps, enable fast retrieval, and keep the organization aligned with legal and accreditation requirements.
How to Improve Records Management Skills
Define the legal medical record: Document what’s included, where it lives, and who owns each component.
Retention schedules: Follow state and federal rules; automate triggers for archival and destruction when permissible.
Access governance: Role-based permissions, break-the-glass protocols, and periodic access reviews.
Version control and metadata: Track authorship, timestamps, amendments, and provenance clearly.
Backup and recovery: Tested backups, defined RPO/RTO targets, and documented disaster recovery playbooks.
Quality checks: Routine completeness and accuracy audits; remediate discrepancies quickly.
Consistency is king—records should tell a single, unbroken story.
How to Display Records Management Skills on Your Resume
12. Quality Assurance
Quality Assurance (QA) monitors and improves the accuracy, completeness, timeliness, and compliance of medical records and coded data—through policies, audits, metrics, and corrective actions.
Why It's Important
QA reduces denials, strengthens patient safety, and underpins reliable reporting. It’s the safety net and the springboard.
How to Improve Quality Assurance Skills
Standardize procedures: Document workflows, coding conventions, and query practices; keep them updated.
Measure what matters: Track accuracy rate, turnaround time, denial trends, and audit findings; share dashboards.
Smart sampling: Risk-based audits on high-impact areas (e.g., high-dollar claims, new service lines, new coders).
Root cause to action: Use corrective and preventive actions (CAPA); verify effectiveness after changes.
Continuous education: Micro-train on error patterns; debrief upgrades and regulatory changes.
QA isn’t a project—it’s a habit baked into daily work.
How to Display Quality Assurance Skills on Your Resume
