Medical Record

Medical records and health information technicians assemble patients' health information including medical history, symptoms, examination results, diagnostic tests, treatment methods, and all other healthcare provider services. Technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security. They regularly communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain additional information.

The increasing use of electronic health records (EHR) will continue to broaden and alter the job responsibilities of health information technicians. For example, with the use of EHRs, technicians must be familiar with EHR computer software, maintaining EHR security, and analyzing electronic data to improve healthcare information. Health information technicians use EHR software to maintain data on patient safety, patterns of disease, and disease treatment and outcome. Technicians also may assist with improving EHR software usability and may contribute to the development and maintenance of health information networks.

Medical records and health information technicians' duties vary with the size of the facility where they work. Technicians can specialize in many aspects of health information.

Some medical records and health information technicians specialize in codifying patients' medical information for reimbursement purposes. Technicians who specialize in coding are called medical coders or coding specialists. Medical coders assign a code to each diagnosis and procedure by using classification systems software. The classification system determines the amount for which healthcare providers will be reimbursed if the patient is covered by Medicare, Medicaid, or other insurance programs using the system. Coders may use several 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 to track treatment, survival, and recovery. This information is used to calculate survivor rates and success rates of various types of treatment, to locate geographic areas with high incidences of certain cancers, and to identify potential participants for clinical drug trials.

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 no direct hands-on patient care.

Medical records and health information technicians usually work a typical 40-hour week. Some overtime may be required. In health facilities that are open 24 hours a day, 7 days a week, technicians may work day, evening, and night shifts. About 14 percent of technicians worked part-time in 2008.

Some medical records and health information technicians specialize in coding medical information for insurance purposes.
Some medical records and health information technicians specialize in coding medical information for insurance purposes.