Medical records technicians and health information technicians are the professionals responsible for ensuring patients’ charts are accurate and complete.
Traditionally, patients’ charts have been paper records. Initiatives in recently enacted health legislation, however, call for the digitization of all medical information over the next ten years.
Medical records technicians and health information technicians will be at the forefront of this transformation, organizing and verifying the individual patients records that will become the basis for a sophisticated electronic medical database and registry.
Many medical records jobs require a degree or certificate. This can also help increase salary and lead to better job opportunities. Check out the programs below which offer free information:
Medical Records and Health Information Technician Job Responsibilities
Medical records technicians are responsible for assembling and organizing individual patients’ medical information, and then entering it into an electronic health record (EHR.) This medical information may include:
- medical histories taken by various health care professionals
- information about symptoms that have caused the patient to seek medical information
- the results of physical examinations
- physicians’ diagnoses
- physicians’ treatment plans and nursing care plans
- physicians’ notes and nursing notes
- x-ray and laboratory test results
- consent forms
The medical records technician is responsible for ensuring all the information entered into the EHR is accurate and complete. The first step in this process involves reviewing any paper documents to make sure all forms are completed, identified and signed. (In the future, as more and more primary interactions are encoded digitally, this step will be a review of electronic documents.) Once all information is verified, the medical records technician will begin entering it into an EHR.
The health information technician is responsible for the maintenance and upkeep of the electronic records database. He or she must be intimately familiar with EHR software, both its use and any trouble shooting that may be required. Additionally, the health information technician is responsible for the security of his or her institution’s electronic database, and for analyzing electronic data that may give insight into patterns of disease and treatment outcomes, when called upon to do so.
Specializations within the medical records and health information technology field include:
Medical Coders: Medical coders are responsible for using classification systems to assign an alphanumeric code to the various components of a medical chart; these codes then act as a kind of shorthand during chart review. These codes are most often used by insurance companies and government agencies like Medicare and Medicaid to determine reimbursement for healthcare-related services.
Medical Billers: Medical billers are responsible for submitting reimbursement claims to insurance companies, government agencies like Medicare or Medicaid, or, at times, to the patients themselves, in order to secure payment for the services rendered by health care professionals.
Cancer Registrars: Cancer registrars are the data collection and management specialists responsible for maintaining the national database of cancer patients. Cancer registrars manage and analyze clinical data on patterns of disease, disease treatment, outcome and survival rates for purposes of research and education.
Medical secretaries and transcriptionists: In addition to transcribing dictated patient notes and assisting physicians and health care professionals with other reports, medical secretaries also frequently update medical records and provide technical support for the information management system.
Medical Records and Health Information Technician Training and Education Requirements
Training and education in health information technology are offered by some colleges and universities, community colleges and technical schools. Bachelors and masters degree programs generally prepare technicians for supervisory or administrative employment. Online coursework is also a viable option for individuals hoping to specialize in this field, as the work does not involve direct patient contact. Colleges and universities will award bachelors or masters degrees in health information management, while two-year community colleges will award associates degrees.
Coursework will typically consist of classes in medical terminology, anatomy and physiology, statistics, database administration, computer programming, quality assurance techniques, and legal and ethical healthcare-related issues.
Medical Records and Health Information Technician Salary and Wages
Medical records and health information technicians work in healthcare facilities, insurance companies, legal firms, pharmaceutical companies, and for the government, usually at the federal level. Earnings depend upon the amount of experience, the geographic location of the job and the industry the technician works for.
Generally speaking, technicians who work in the private sector earn more than technicians who work in the public sector or for non-profits. Technicians who work for pharmaceutical companies earn the most with an hourly mean wage of $29.43, and an annual mean wage of $61,210, while technicians who work in physicians’ offices earn the least with an hourly mean wage of $13.69 and an annual mean wage of $28,460.*
*According to the BLS, http://www.bls.gov/oco/
Medical Records and Health Information Technician Certifications
While certification is not a legal requirement for employment in any state, employers look more favorably on job candidates who have taken the time to become certified in their specialty. Two professional organizations offer some form of health technology certification.
The American Health Information Management Association (AHIMA) offers six levels of certification:
- Registered Health Information Technician (RHIT)
- Certified Coding Associate (CCA)
- Certified Coding Specialist (CCS)
- Certified Coding Specialist-Physician Based (CCS-P)
- Certified Health Data Analyst (CHDA)
- Certification In Healthcare Privacy and Security (CHPS)
The American Academy of Professional Coders (AAPC) offers five levels of certification:
- Certified Professional Coder (CPC)
- Certified Professional Coder, Outpatient Hospital (CPC-H)
- Certified Professional Coder, Payer (CPC-P)
- Certified Interventional Radiology Cardiovascular Coder (CIRCC)
- Certified Professional Auditor (CPMA)
The Board of Medical Specialty Coding (BMSC) and Professional Association of Health care Coding Specialists (PAHCS) offer certification in the health information technology specialty of medical coding as well, but these credentials don’t carry the same prestige as AHIMA’s and AAPC’s.
The National Cancer Registrars Association (NCRA) offers certification for health technicians interested in working as cancer registrars.
Medical Records and Health Information Technician Professional Associations
The four professional organizations in the field of health information technology are the American Health Information Management Association, the American Academy of Professional Coders, the Board of Medical Specialty Coding and the Professional Association of Health care Coding Specialists.