 Every
time a patient receives health care, a record is maintained of the
observations, medical or surgical interventions, and treatment outcomes.
This record includes information that the patient provides concerning
his or her symptoms and medical history, the results of examinations,
reports of x-rays and laboratory tests, diagnoses, and treatment plans.
Medical records and health information technicians organize and evaluate
these records for completeness and accuracy.
Technicians assemble
patients' health information, making sure that patients' initial medical
charts are complete, that all forms are completed and properly
identified and authenticated, and that all necessary information is in
the computer. They regularly communicate with physicians and other
health care professionals to clarify diagnoses or to obtain additional
information. Technicians regularly use computer programs to tabulate and
analyze data to improve patient care, better control cost, provide
documentation for use in legal actions, or use in research studies.
 Medical records and
health information technicians' duties vary with the size of the
facility where they work. In large to medium-size facilities,
technicians might specialize in one aspect of health information or
might supervise health information clerks and transcriptionists while a
medical records and health information administrator manages the
department. In small facilities, a credentialed medical records and
health information technician may have the opportunity to manage the
department.
Note: Some resources in this section are provided by the US Department
of Labor, Bureau of Labor Statistics.
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