Medical records and health information technician job description

What Do Medical Records Technicians Do? Job Description of a Medical Records Technician
Medical Records Technicians are responsible for organizing and managing patients’ health information data. They ensure paperwork is properly filled out, verify accuracy and accessibility of files, and are responsible for keeping all files secure. Medical Records Technicians communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain additional information. They also must transfer the data from a doctor’s notes into a patient’s permanent medical record. The Medical Records Technician maintains electronic health records (EHR) databases and analyze electronic data.

Medical Records Technician Career Options
According to the Bureau of Labor Statistics, Medical Records Technician jobs are expected to increase 21% between 2010 and 2020, which is faster than average for most occupations. Medical Records Technicians mainly work in hospitals and doctor’s office. The work is primarily computer-based, although a Medical Records Technician must communicate with doctors and nursers to clarify unclear information. The Medical Records Technician salary varies based on experience.

Choosing the right Health Information degree program is crucial when preparing for a Medical Records Technician career. Fremont University offers an associate’s degree in Health Information Technology that takes just 15 months to complete and will prepare you for the demands of a Medical Records Technician job. The program provides the knowledge and real-world training you need for a successful career in Healthcare Information. Enroll today and be on your way to an exciting and rewarding career as a Medical Records Technician in just over one year!

Special Offer

We are looking for a meticulous medical records technician to accurately create and maintain electronic medical records for our facility. Your duties will include obtaining patient information from healthcare professionals, categorizing conditions, treatments, and diagnoses, as well as creating permanent medical records for reference purposes.

To ensure success as a medical records technician, you should possess knowledge of electronic health record management systems and demonstrate experience in a similar role. Ultimately, a top-notch Medical Records Technician is someone who can be entrusted with the responsibility of converting patient history into accurate medical records.

Medical Records Technician Responsibilities:

• Contributing to improved and cost-effective patient care by creating permanent medical records.
• Transcribing medical data from doctors' written or spoken notes, including symptoms, possible diagnoses, prescribed medications, and tests.
• Categorizing conditions, treatments, and diagnoses using standardized healthcare codes and software programs.
• Entering and updating medical records for healthcare professionals' and insurance companies' reference.
• Collaborating with healthcare providers to ensure the accuracy of medical records.
• Updating medical records in a timely manner.
• Ensuring that patient data and medical records are protected and remain confidential.

Medical Records Technician Requirements:

• Registered Health Information Technician (RHIT).
• PAHCS or similar healthcare coding certification would be advantageous.
• 1-2 years of experience in a similar role.
• Knowledge of electronic medical record management systems, such as RXNT and AdvancedMD.
• Extensive experience in categorizing and coding written and spoken patient information.
• Proficiency in medical terminology and collaborating with healthcare professionals.
• Ability to maintain and update medical records in a timely manner.
• Experience in data encryption and protection.
• Advanced ability to perform detailed tasks under pressure.
• Excellent written and verbal communication skills.

Job Duties and Tasks for: "Medical Records and Health Information Technician"

1) Protect the security of medical records to ensure that confidentiality is maintained.

2) Process patient admission and discharge documents.

3) Review records for completeness, accuracy and compliance with regulations.

4) Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.

5) Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.

6) Release information to persons and agencies according to regulations.

7) Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.

8) Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department.

9) Transcribe medical reports.

10) Identify, compile, abstract and code patient data, using standard classification systems.

11) Resolve/clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others to get additional information and by participating in the coding team's regular meetings.

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12) Train medical records staff.

13) Assign the patient to one of several hundred "diagnosis-related groups", or DRGs, using appropriate computer software.

14) Post medical insurance billings.

15) Process and prepare business and government forms.

16) Contact discharged patients, their families, and physicians to maintain registry with follow-up information, such as quality of life and length of survival of cancer patients.

17) Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, and other users.

18) Consult classification manuals to locate information about disease processes.

19) Compile medical care and census data for statistical reports on diseases treated, surgery performed, and use of hospital beds.

20) Develop in-service educational materials.

Job Description for "Medical Records and Health Information Technician" continued here...

Part 1
Duties / Tasks Part 2
Activities Part 3
Skills Part 4
Abilities Part 5
Knowledge

"Medical Records and Health Information Technician"   Holland / RIASEC Career Code:  C-R-I        SOC:  29-2071.00

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