A medical records technician (also known as a health information tech) is an administrative job which primarily involves administrative tasks such as record keeping in a medical office setting. They do not have anything to do directly with a patient’s condition, diagnosis, or treatment. This person keeps patient records updated and complies with healthcare coding system standards.
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How to Become a Medical Records Technician
To become a medical records technician, candidates normally have a high school diploma or equivalent. However, most employers are beginning to require formal training or an associate’s degree that includes skills such as creating, managing, editing, and interpreting medical records. Also, knowledge of medical jargon and terminology would be important. Candidates with computer system knowledge, coding, medical classifications, standards, and insurance training also have a higher chance for employment.
According to the Bureau of Labor Statistics, it has become a trend for employers to want you to be certified as a medical technician prior to or during the first couple of weeks of employment. There are many training programs that are accredited such as the Registered Health Information Technician program which gives licenses through the American Health Information Management Association. There is also the Certified Tumor Registrar program, which gives certification from National Cancer Registrars Association and the American Academy of Coders.
The RHIT certification exam consists of 7 domains focusing on: revenue cycles, legal matters, quality assurance, information technology, compliance, coding and data analysis. It takes 3.5 hours and is comprised of 150 questions. You pass with a scale score of 300 out 400.
The CTR certification exam consist of 6 domains focusing on: data quality assurance, analysis and data usage, operations and management, cancer committee and conference, and activities of centralized registries. This exam is both open and closed book consisting of 235 questions within a 4.5 hour allotted time frame. It is also necessary to score 300 out of 400 on the scale to pass.
Job Description of a Medical Records Technician
Whenever a patient sees a doctor, there are notes from the doctor that a medical records technician must add to a patient’s record such as:
- the existing health conditions
- medical history of the patient
- diagnoses reports
- medications or treatments prescribed
- schedules of treatments
- subsequent recovery
A medical records technician is responsible to track all aspects of a patient’s medical history and care received. The accuracy and quality of this recorded data will be pertinent for insurance company reimbursements for services rendered to the patients from your employer. Therefore, you should have high analytical, technical, and computer skills in addition to being detailed-oriented and having high integrity when entering this career field. You will be maintaining and accessing patient’s personal information, well-being, health procedures, and medical problems.
The Bureau of Labor Statistics reported that 38% of medical record technicians work in hospital settings in 2014 followed by physicians offices at 21%. Most work full time, and those who do work in facilities that are open 24 hours a day may have to work evening hours or night shifts.
Medical Records Technician Job Posting
Let’s look at a job description posted by the Department of Veteran Affairs. This job announcement is looking for a person to perform the following responsibilities:
- Performs inpatient and/or outpatient coding on billable and/or non-billable patient care encounters and develops skill and knowledge of medical record coding and has basic knowledge of medical terminology, anatomy and physiology, and diseases.
- Selects and assigns codes from the current version of the International Classification of Diseases- Clinical Modification, Current Procedural Terminology, Evaluation and Management Codes, HCPCS, and modifier assignment.
- Assigns diagnosis or diagnoses and procedure code(s) based on the accepted coding practices, guidelines, conventions, and policy with instruction from a senior coder.
- Reviews record documentation to abstract all required medical, ancillary, demographic, social and administrative data with guidance and instruction from the supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
- Refers questions about coding and documentation from providers to a senior coder or supervisor for resolution or guidance.
- Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin. Any identified data errors are reviewed with a senior coder or the supervisor for corrections as needed.
- Uses a variety of window-based applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; develops use of the medical record applications (Vista and CPRS) as well as the code selection software. Ensures current versions of all software applications are loaded and functional after any updates or changes.
This position was posted to run 02/25/2019 until 03/11/2019 with a salary range of $30,036 to $59,934 per year on USAjobs.gov (link opens in a new tab). USAjobs.gov is an official website of the United States government and part of the U.S. Office of Personnel Management.
Medical Records Technician Career Video Transcript
Every time nurses or physicians treat their patients, they need to record what they have seen and done; from x-rays and examination notes, to forming diagnoses and treatment plans. Medical records technicians organize and maintain these medical documents. These technicians do not provide patient care; instead, they work behind the scenes with care providers to fill in missing information, process forms, and ensure that insurance companies receive correct records. They use coding systems to document patient information for billing and record keeping, and are responsible for the privacy of patient files.
These technicians work at a computer for prolonged periods. Whether they’re updating clinic records or tracking a patient’s outcomes, accuracy is essential, so medical records technicians must pay strict attention to detail. Some work with data to analyze health care costs and identify health data trends. Most health information technicians work full-time. In health care facilities that are open 24/7, such as hospitals or nursing care facilities, technicians may need to work evenings or overnight shifts.
While it’s possible to enter the field with a high school diploma and work experience in a health care setting, most employers prefer to hire candidates who’ve earned a certificate in this field. Passing a certification exam is often required. Medical records technicians provide a service that is critical for quality patient care.
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Medical Records and Health Information Technicians.
National Center for O*NET Development. 29-2071.00. O*NET OnLine.
The career video is in the public domain from the U. S. Department of Labor, Employment and Training Administration.