Whenever a patient is delivered health care, a record is created of the observations, medical or surgical interventions, and treatment outcomes. This information includes data provided by the patient including symptoms, the results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians inspect and review these records for completeness and accuracy.
Technicians compile patients’ health information, and ensure that the patients’ initial medical charts are complete, that all forms are completed, properly identified ,authenticated, and that all needed information has been input to the computer. Routinly, they communicate with physicians and other health care providers to check diagnoses or to get more information. Technicians regularly use medical computer programs to tabulate and analyze data for the purposes of improving patient care, controlling costs, provide documentation for use in legal actions, or use in clinical studies.
Medical records and health information technicians’ duties are very much related to facility size. Technicians might specialize in one aspect of health information or might supervise health information clerks and transcriptionists In large to medium-size facilities, while a medical records and health information administrator manages the department. In smaller facilities, a credentialed medical records and health information technician could very well manage the whole department
Although Medical records and health information technicians are primarily employed in the health provider industries, a small number work for other types of entities such as pharmaceutical firms, clinical research organizations and others.
Following is data from the United States Bureau of Labor Statistics regarding salaries. The information was assembled in May 2009 and is the most current available.
Medical records and health information technicians employed in a hospital can expect to earn a mean salary of $35,870, if employed by a physician’s office the mean salary is $28.460, a nursing care facility pays a mean salary of $33,100 and an outpatient care center’s mean salary is $30,650.*
In non-patient care settings the Bureau reports that those who work in the Federal Executive Branch earn a mean salary of $45,120 while in pharmaceutical and medicine manufacturing it is $61,210, the mean in business, professional, labor, political, and similar organizations is $45.850 , while in other support services it is $44,270 and clinical research organizations have a mean salary of $42,050.*
*According to the BLS, http://www.bls.gov/oco/
Training and Education Requirements
As a minimum, medical records and health information technicians who just beginning their careers, usually have an associate degree from a community of junior college. In addition to the usual core courses, degree specific courses in medical terminology, coding and abstraction of data, anatomy and physiology, statistics, database management, quality improvement methodology and computer training are required. Students who have high school biology, chemistry, health and computer course work may have an edge in the admissions process.
Job Description and Outlook
Medical records and health information technicians usually are employed by health care providers such as hospitals, nursing home and clinics. In terms of employment numbers, medical records and health information technicians comprise around 170,000 jobs in the US. About 2 out of 5 jobs are in hospitals. Usually medical records and health information technicians work with computerized systems that maintain reports on patients. The primary task of a medical records and health information technician is to make sure that the medical records is complete and correct. In order to do this they track patient medical histories, examine records to ensure all forms are included in the record and signed, and ensure that the record information is correct and available to doctors and nurses.
Maintenance of proper medical records is vital for insurance purposes and/or in the event the patient returns to the provider.
These records must be maintained for insurance purposes and in the event the patient returns to the facility.
Medical records and health information technicians also collect information from the records such as disease, length of stay, and other information that can help doctors and scientists conduct research.
As in so many health care occupations, specialization is also available for medical records and health information technicians. Areas of specialization include:
- Coding patients’ medical information for insurance purposes
- Tumor Registry
Employment for medical records and health information technicians is anticipated to grow more than average. Job prospects are excellent, especially for technicians with experience in medical coding.
The employment rate for this position is estimated to be 18% through 2016. This is more rapid than for any other occupation and is due to the effects of the new health care legislation passed in 2010 that includes calling for an electronic medical record as well as because of the demands placed on providers by insurance companies, government and private regulators, courts and patients.*
*According to the BLS, http://www.bls.gov/oco/
These jobs will be in doctor’s offices (particularly large group practices), home health care services, outpatient care centers, nursing facilities and residential care facilities and to a lesser extent hospitals.
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