What Medical Records and Health Information Technicians Do

Medical records and health information technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security in both paper and electronic systems. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.

Duties

All technicians document patients' health information, including the medical history, symptoms, examination and test results, treatments, and other information about healthcare provider services. Medical records and health information technicians' duties vary with the size of the facility in which they work.

Medical records and health information technicians typically do the following:

• Review patient records for timeliness, completeness, accuracy, and appropriateness of health data
• Organize and maintain data for clinical databases and registries
• Track patient outcomes for quality assessment
• Use classification software to assign clinical codes for reimbursement and data analysis 
• Electronically record data for collection, storage, analysis, retrieval, and reporting
• Protect patients’ health information for confidentiality, authorized access for treatment, and data security

Although medical records and health information technicians do not provide direct patient care, they work regularly with physicians and other healthcare professionals. They meet with these workers to clarify diagnoses or to get additional information to make sure that records are complete and accurate.

The increasing use of electronic health records (EHRs) will continue to change the job responsibilities of medical records and health information technicians. Technicians will need to be familiar with, or be able to learn, EHR computer software, follow EHR security and privacy practices, and analyze electronic data to improve healthcare information as more healthcare providers and hospitals adopt EHR systems.

Medical records and health information technicians can specialize in many aspects of health information. Most work as medical coders, sometimes called coding specialists, or as cancer registrars.

Medical coders typically do the following:

• Review patient information for preexisting conditions such as diabetes
• Retrieve patient records for medical personnel
• Work as a liaison between the health clinician and billing offices

Cancer registrars typically do the following:

• Review patient records and pathology reports for completeness and accuracy
• Assign classification codes to represent the diagnosis and treatment of cancers and benign tumors
• Conduct annual followups to track treatment, survival, and recovery
• Analyze and compile cancer patient information for research purposes
• Maintain facility, regional, and national databases of cancer patients

Source: Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition