Medical
records and health information technicians assemble patients' health
information including medical history, symptoms, examination results,
diagnostic tests, treatment methods, and all other healthcare provider
services. Technicians organize and manage health information data by
ensuring its quality, accuracy, accessibility, and security. They
regularly communicate with physicians and other healthcare professionals
to clarify diagnoses or to obtain additional information.
The increasing use of
electronic health records (EHR) will continue to broaden and alter the
job responsibilities of health information technicians. For example,
with the use of EHRs, technicians must be familiar with EHR computer
software, maintaining EHR security, and analyzing electronic data to
improve healthcare information. Health information technicians use EHR
software to maintain data on patient safety, patterns of disease, and
disease treatment and outcome. Technicians also may assist with
improving EHR software usability and may contribute to the development
and maintenance of health information networks.
Medical records and
health information technicians' duties vary with the size of the
facility where they work. Technicians can specialize in many aspects of
health information.
Some medical records
and health information technicians specialize in codifying patients'
medical information for reimbursement purposes. Technicians who
specialize in coding are called medical coders or coding specialists.
Medical coders assign a code to each diagnosis and procedure by using
classification systems software. The classification system determines
the amount for which healthcare providers will be reimbursed if the
patient is covered by Medicare, Medicaid, or other insurance programs
using the system. Coders may use several coding systems, such as those
required for ambulatory settings, physician offices, or long-term care.
Medical
records and health information technicians also may specialize in cancer
registry. Cancer (or tumor) registrars maintain facility, regional, and
national databases of cancer patients. Registrars review patient records
and pathology reports, and assign codes for the diagnosis and treatment
of different cancers and selected benign tumors. Registrars conduct
annual followups to track treatment, survival, and recovery. This
information is used to calculate survivor rates and success rates of
various types of treatment, to locate geographic areas with high
incidences of certain cancers, and to identify potential participants
for clinical drug trials.
Note: Some resources in this section are provided by the US Department
of Labor, Bureau of Labor Statistics.
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