A patient needs to receive surgical or medical interventions, treatment outcomes, and health care. This record comprises of information that the patient provides pertaining to his/her medical history and symptoms, reports of X rays and laboratory tests, treatment plans, and diagnoses.
Medical records and health information technicians plan, organize, and assess health records of patients for accuracy and completeness. The work of health information technicians is to accumulate health information of patients, ensure that patients' primarily charts are duly filled in, all forms are duly completed, properly identified, and authenticated, and record all necessary information in the computer.
Health information technicians interact with health care professionals and physicians with the intention of obtaining additional information and clarifying diagnoses. These technicians use computer programs to analyze and tabulate data to provide documentation for legal actions, improve patient care, and enhance research studies.
Health information technicians and medical records' responsibilities may vary with the nature of work and size of the organization. In some large medical facilities, health information technicians may specialize in one area of health information. They may administer health information clerks and transcriptionists. A medical records and health information administrator oversees the department.
In small medical facilities, a health information technician and credentialed medical records may administer the department. Many health information technicians and medical records specialize in coding medical information of the patient for insurance purposes. A technician who specialize in coding are known as medical record coder, abstractor, health information coder, or coding specialist.
The work of these technicians is to assign a code to each procedure and diagnosis based on their processes disease knowledge. Subsequently, these technicians use classification systems software in order to assign the patient diagnosis related groups or DRG. The diagnosis related groups determine the amount for which the hospital shall be reimbursed if the patient is recovered by Medicare and other insurance programs. Besides the DRG system, coders use other coding systems that are required for long-term care, physician offices, and ambulatory settings.
Medical records and health information technicians may specialize in cancer registry. Cancer or tumor registrars maintain national and regional databases of cancer patients. The work of registrars is to examine patients' records and pathology reports, and assign codes for the treatment and diagnosis for selected benign tumors and different cancers. The job of a registrar is to organize yearly follow-ups on all patients in the registry to record their treatment, recovery, and survival. Public health organizations and physicians use this information to compute success rates and survivor rates of many types of treatment and classify prospective participants for clinical drug trials. Public health officials use cancer registry data with the purpose of targeting areas for the distribution of resources to provide screening intervention.
Medical records and health information technicians perform their work in comfortable and pleasant offices. This is a kind of health related profession wherein practitioners get little or no direct interaction with patients. Correctness is necessary in this profession. Technicians should pay attention to every detail. Technicians who work at computers for long time ought to guard against muscle pain and eye strain.
Generally, medical records and health information technicians work forty hours a week. However, they require working overtime. Technicians may work evening, night, and day shifts in the departments which are open throughout the day and nights.
Training and Educational Qualification
Candidates who would like to get into this field need to have an associate degree from junior or community college. Upon completing this degree, they may become medical records and health information technicians. Many employers prefer candidates who have become registered health information technicians. These professions may get promotion based upon their educational qualification and amount of experience.
Generally, many community colleges offer online distance learning courses or flexible course schedule with the intention of providing quality education. These courses are well built and tailored to impart high standard education. These courses incorporate various aspects of health comprising of health data standards, legal aspects of health information, physiology and anatomy, medical terminology, coding and abstraction of data, database management, statistics, computer science, and quality improvement methods.