Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians organize and evaluate these records for completeness and accuracy.
Technicians assemble patients' health information, making sure that patients' initial medical charts are complete, that all forms are completed and properly identified and authenticated, and that all necessary information is in the computer. They regularly communicate with physicians and other health care professionals to clarify diagnoses or to obtain additional information. Technicians regularly use computer programs to tabulate and analyze data to improve patient care, better control cost, provide documentation for use in legal actions, or use in research studies.
Medical records and health information technicians' duties vary with the size of the facility where they work. In large to medium-size facilities, technicians might specialize in one aspect of health information or might supervise health information clerks and transcriptionists while a medical records and health information administrator manages the department. In small facilities, a credentialed medical records and health information technician may have the opportunity to manage the department.
Some medical records and health information technicians specialize in coding patients' medical information for insurance purposes. Technicians who specialize in coding are called health information coders, medical record coders, coder/abstractors, or coding specialists. These technicians assign a code to each diagnosis and procedure, relying on their knowledge of disease processes. Technicians then use classification systems software to assign the patient to one of several hundred "diagnosis-related groups," or DRGs. The DRG determines the amount for which the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the DRG system. In addition to the DRG system, coders use other coding systems, such as those required for ambulatory settings, physician offices, or long-term care.
Medical records and health information technicians also may specialize in cancer registry. Cancer (or tumor) registrars maintain facility, regional, and national databases of cancer patients. Registrars review patient records and pathology reports, and assign codes for the diagnosis and treatment of different cancers and selected benign tumors. Registrars conduct annual followups on all patients in the registry to track their treatment, survival, and recovery. Physicians and public health organizations then use this information to calculate survivor rates and success rates of various types of treatment, locate geographic areas with high incidences of certain cancers, and identify potential participants for clinical drug trials. Public health officials also use cancer registry data to target areas for the allocation of resources to provide intervention and screening.
Work environment. Medical records and health information technicians work in pleasant and comfortable offices. This is one of the few health-related occupations in which there is little or no direct contact with patients. Because accuracy is essential in their jobs, technicians must pay close attention to detail. Technicians who work at computer monitors for prolonged periods must guard against eyestrain and muscle pain.
Medical records and health information technicians usually work a 40-hour week. Some overtime may be required. In hospitals—where health information departments often are open 24 hours a day, 7 days a week—technicians may work day, evening, and night shifts.
| 1. | Protect the security of medical records to ensure that confidentiality is maintained. |
| 2. | Process patient admission and discharge documents. |
| 3. | Review records for completeness, accuracy and compliance with regulations. |
| 4. | Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts. |
| 5. | Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer. |
| 6. | Release information to persons and agencies according to regulations. |
| 7. | Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information. |
| 8. | Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department. |
| 9. | Transcribe medical reports. |
| 10. | Identify, compile, abstract and code patient data, using standard classification systems. |
| 11. | Resolve or clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings. |
| 12. | Train medical records staff. |
| 13. | Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software. |
| 14. | Post medical insurance billings. |
| 15. | Process and prepare business and government forms. |
| 16. | Contact discharged patients, their families, and physicians to maintain registry with follow-up information, such as quality of life and length of survival of cancer patients. |
| 17. | Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, or other users. |
| 18. | Consult classification manuals to locate information about disease processes. |
| 19. | Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds. |
| 20. | Develop in-service educational materials. |
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