Medical Records & Health Information Technicians
Also called: Coder, Health Information Specialist, Medical Records Analyst, Medical Records Clerk
Produced by CareerOneStop
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Every time nurses or physicians treat their patients, they need to record what they have seen and done; from x-rays and examination notes, to forming diagnoses and treatment plans. Medical records technicians organize and maintain these medical documents. These technicians do not provide patient care; instead, they work behind the scenes with care providers to fill in missing information, process forms, and ensure that insurance companies receive correct records. They use coding systems to document patient information for billing and recordkeeping, and are responsible for the privacy of patient files. These technicians work at a computer for prolonged periods. Whether they’re updating clinic records or tracking a patient's outcomes, accuracy is essential, so medical records technicians must pay strict attention to detail. Some work with data to analyze health care costs and identify health data trends. Most health information technicians work full-time. In health care facilities that are open 24/7, such as hospitals or nursing care facilities, technicians may need to work evening or overnight shifts. While it’s possible to enter the field with a high school diploma and work experience in a health care setting, most employers prefer to hire candidates who've earned a certificate in this field. Passing a certification exam is often required. Medical records technicians provide a service that is critical for quality patient care.
What they do: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 health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system.
On the job, you would:
- Protect the security of medical records to ensure that confidentiality is maintained.
- Review records for completeness, accuracy, and compliance with regulations.
- Retrieve patient medical records for physicians, technicians, or other medical personnel.
- administrative services
- customer service
Arts and Humanities
- English language
Engineering and Technology
- computers and electronics
- reading work related information
- listening to others, not interrupting, and asking good questions
- noticing a problem and figuring out the best way to solve it
- listen and understand what people say
- read and understand what is written
Ideas and Logic
- group things in different ways
- order or arrange things
People interested in this work like activities that include data, detail, and regular routines.
They do well at jobs that need:
- Attention to Detail
You might use software like this on the job:
Data base user interface and query software
Document management software
- Fox Meadows Accent Data Manager
- Hyland Software OnBase