In any hospital, clinic, or other health care facility, permanent records are created and maintained for all the patients treated by the staff. Each patient’s medical record describes in detail his or her condition over time. Entries include illness and injuries, operations, treatments, outpatient visits, and the progress of hospital stays. Medical record technicians compile, code, and maintain these records. They also tabulate and analyze data from groups of records in order to assemble reports. They review records for completeness and accuracy; assign codes to the diseases, operations, diagnoses, and treatments according to detailed standardized classification systems; and post the codes on the medical record. They transcribe medical reports; maintain indices of patients, diseases, operations, and other categories of information; compile patient census data; and file records. In addition, they may direct the day-to-day operations of the medical records department. They maintain the flow of records and reports to and from other departments, and sometimes assist medical staff in special studies or research that draws on information in the records. There are approximately 159,000 medical record technicians employed in the United States.
Medical Record Technician Career History
Medical practitioners have been recording information about their patients’ illnesses and treatments for hundreds of years. Before the 20th and 21st centuries, such records were kept mostly to help the practitioners retain and learn as much as possible from their own experience. Because there was little centralization or standardization of this information, it was difficult to organize and share the knowledge that resulted from studying many instances of similar cases.
By the early 1900s, medical record keeping was changing, along with many other aspects of health care. Medicine was more sophisticated, scientific, and successful in helping patients. Hospitals were increasingly becoming accepted as the conventional place for middle-class patients to go for care, and as a result, hospitals became more numerous and better organized. As hospitals grew larger and served more patients, the volume of patient records increased proportionately. With medical record keeping becoming more important and time consuming, it was most efficient and sensible to centralize it within the hospital. Recommendations by distinguished committees representing the medical profession also encouraged standardized record-keeping procedures.
By the 1920s, many hospitals in the United States had central libraries of patient information, with employees specifically hired to keep these records in good order. As time passed, their tasks became more complicated. The employees responsible for this work, who used to be called medical record librarians, eventually became differentiated into two basic professional categories: medical record administrators and medical record technicians. In 1953, the first formal training programs for medical record technicians started up in hospital schools and junior colleges.
In recent years, the computerization of records, the growing importance of privacy and freedom of information issues, and the changing requirements of insurance carriers have all had major impacts on the field of medical records technology. These areas will undoubtedly continue to reshape the field in future years.
Medical Record Technician Job Description
A patient’s medical record consists of all relevant information and observations of any health care workers who have dealt with the patient. It may contain, for example, several diagnoses, X-ray and laboratory reports, electrocardiogram tracings, test results, and drugs prescribed. This summary of the patient’s medical history is very important to the physician in making speedy and correct decisions about care. Later, information from the record is often needed in authenticating legal forms and insurance claims. The medical record documents the adequacy and appropriateness of the care received by the patient and is the basis of any investigation when the care is questioned in any way.
Patterns and trends can be traced when data from many records are considered together. These types of statistical reports are used by many different groups. Hospital administrators, scientists, public health agencies, accrediting and licensing bodies, people who evaluate the effectiveness of current programs or plan future ones, and medical reimbursement organizations are examples of some groups that rely on health care statistics. Medical records can provide the data to show whether a new treatment or medication really works, the relative effectiveness of alternative treatments or medications, or patterns that yield clues about the causes or methods of preventing certain kinds of disease.
Medical record technicians are involved in the routine preparation, handling, and safeguarding of individual records as well as the statistical information extracted from groups of records. Their specific tasks and the scope of their responsibilities depend a great deal on the size and type of the employing institution. In large organizations, there may be a number of technicians and other employees working with medical records. The technicians may serve as assistants to the medical record administrator as needed or may regularly specialize in some particular phase of the work done by the department. In small facilities, however, technicians often carry out the whole range of activities and may function fairly independently, perhaps bearing the full responsibility for all day-to-day operations of the department. A technician in a small facility may even be a department director. Sometimes technicians handle medical records and also spend part of their time helping out in the business or admitting office.
Whether they work in hospitals or other settings, medical record technicians must organize, transfer, analyze, preserve, and locate vast quantities of detailed information when needed. The sources of this information include physicians, nurses, laboratory workers, and other members of the health care team.
In a hospital, a patient’s cumulative record goes to the medical record department at the end of the hospital stay. A technician checks over the information in the file to be sure that all the essential reports and data are included and appear accurate. Certain specific items must be supplied in any record, such as signatures, dates, the patient’s physical and social history, the results of physical examinations, provisional and final diagnoses, periodic progress notes on the patient’s condition during the hospital stay, medications prescribed and administered, therapeutic treatments, surgical procedures, and an assessment of the outcome or the condition at the time of discharge. If any item is missing, the technician sends the record to the person who is responsible for supplying the information. After all necessary information has been received and the record has passed the review, it is considered the official document describing the patient’s case.
The record is then passed to a medical record coder. Coders are responsible for assigning a numeric code to every diagnosis and procedure listed in a patient’s file. Most hospitals in the United States use a nationally accepted system for coding. The lists of diseases, procedures, and conditions are published in classification manuals that medical records personnel refer to frequently. By reducing information in different forms to a single consistent coding system, the data contained in the record is rendered much easier to handle, tabulate, and analyze. It can be indexed under any suitable heading, such as by patient, disease, type of surgery, physician attending the case, and so forth. Cross-indexing is likely to be an important part of the medical record technician’s job. Because the same coding systems are used nearly everywhere in the United States, the data may be used not only by people working inside the hospital, but may also be submitted to one of the various programs that pool information obtained from many institutions.
After the information on the medical record has been coded, technicians may use a packaged computer program to assign the patient to one of several hundred diagnosis-related groupings, or DRGs. The DRG for the patient’s stay determines the amount of money the hospital will receive if the patient is covered by Medicare or one of the other insurance programs that base their reimbursement on DRGs.
Because information in medical records is used to determine how much hospitals are paid for caring for patients, the accuracy of the work done by medical records personnel is vital. A coding error could cause the hospital or patient to lose money.
Another vital part of the job concerns filing. Regardless of how accurately and completely information is gathered and stored, it is worthless unless it can be retrieved promptly. If paper records are kept, technicians are usually responsible for preparing records for storage, filing them, and getting them out of storage when needed. In some organizations, technicians supervise other personnel who carry out these tasks.
In many health care facilities, computers, rather than paper, are used for nearly all the medical record keeping. In such cases, medical and nursing staff make notes on an electronic chart. They enter patient-care information into computer files, and medical record technicians access the information using their own terminals. Computers have greatly simplified many traditional routine tasks of the medical records department, such as generating daily hospital census figures, tabulating data for research purposes, and updating special registries of certain types of health problems, such as cancer and stroke.
In the past, some medical records that were originally on paper were later photographed and stored on microfilm, particularly after they were a year or two old. Medical record technicians may be responsible for retrieving and maintaining those films. It is not unusual for a health care institution to have a combination of paper and microfilm files as well as computerized record storage, reflecting the evolution of technology for storing information.
Confidentiality and privacy laws have a major bearing on the medical records field. The laws vary in different states for different types of data, but in all cases, maintaining the confidentiality of individual records is of major concern to medical records workers. All individual records must be in secure storage but also be available for retrieval and specified kinds of properly authorized use. Technicians may be responsible for retrieving and releasing this information. They may prepare records to be released in response to a patient’s written authorization, a subpoena, or a court order. This requires special knowledge of legal statutes and often requires consultation with attorneys, judges, insurance agents, and other parties with legitimate rights to access information about a person’s health and medical treatment.
Medical record technicians may participate in the quality assurance, risk management, and utilization review activities of a health care facility. In these cases, they may serve as data abstractors and data analysts, reviewing records against established standards to ensure quality of care. They may also prepare statistical reports for the medical or administrative staff that reviews appropriateness of care.
With more specialized training, medical record technicians may participate in medical research activities by maintaining special records, called registries, related to such areas as cancer, heart disease, transplants, or adverse outcomes of pregnancies. In some cases, they are required to abstract and code information from records of patients with certain medical conditions. These technicians also may prepare statistical reports and trend analyses for the use of medical researchers.
Medical Record Technician Career Requirements
If you are contemplating a career in medical records, you should take as many high school English classes as possible, because technicians need both written and verbal communication skills to prepare reports and communicate with other health care personnel. Basic math or business math is very desirable because statistical skills are important in some job functions. Biology courses will help to familiarize yourself with the terminology that medical record technicians use. Other science courses, computer training, typing, and office procedures are also helpful.
Most employers prefer to hire medical record technicians who have completed a two-year associate’s degree program accredited by the American Medical Association’s Commission on Accreditation of Allied Health Professions and the American Health Information Management Association (AHIMA). There are 184 of these accredited programs available throughout the United States, mostly offered in junior and community colleges. They usually include classroom instruction in such subjects as anatomy, physiology, medical terminology, medical record science, word processing, medical aspects of recordkeeping, statistics, computers in health care, personnel supervision, business management, English, and office skills.
In addition to classroom instruction, the student is given supervised clinical experience in the medical records departments of local health care facilities. This provides students with practical experience in performing many of the functions learned in the classroom and the opportunity to interact with health care professionals.
Certification or Licensing
Medical record technicians who have completed an accredited training program are eligible to take a national qualifying examination to earn the credential of registered health information technician (RHIT). Most health care institutions prefer to hire individuals with an RHIT credential as it signifies that they have met the standards established by the AHIMA as the mark of a qualified health professional. AHIMA also offers certification to medical coders and health information administrators.
Medical records are extremely detailed and precise. Sloppy work could have serious consequences in terms of payment to the hospital or physician, validity of the patient records for later use, and validity of research based on data from medical records. Therefore, a prospective technician must have the capacity to do consistently reliable and accurate routine work. Records must be completed and maintained with care and attention to detail. You may be the only person who checks the entire record, and you must understand the responsibility that accompanies this task.
The technician needs to be able to work rapidly as well as accurately. In many medical record departments, the workload is very heavy, and you must be well organized and efficient in order to stay on top of the job. You must be able to complete your work accurately, in spite of interruptions, such as phone calls and requests for assistance. You also need to be discreet, as you will deal with records that are private and sometimes sensitive. Computer skills also are essential, and some experience in transcribing dictated reports may be useful.
Exploring Medical Record Technician Career
To learn more about this and other medical careers, you may be able to find summer, part-time, or volunteer work in a hospital or other health care facility. Sometimes such jobs are available in the medical records area of an organization. You may also be able to arrange to talk with someone working as a medical record technician or administrator. Faculty and counselors at schools that offer medical record technician training programs may also be good sources of information. You also can learn more about this profession by reading journals and other literature available at a public library.
Although two out of five of the 159,000 medical record technicians employed in the United States work in hospitals, many work in other health care settings, including health maintenance organizations (HMOs), industrial clinics, skilled nursing facilities, rehabilitation centers, large group medical practices, ambulatory care centers, and state and local government health agencies. Technicians also work for computer firms, consulting firms, and government agencies. Records are maintained in all these facilities, although record-keeping procedures vary.
Not all medical record technicians are employed in a single health care facility; some serve as consultants to several small facilities. Other technicians do not work in health care settings at all. They may be employed by health and property liability insurance companies to collect and review information on medical claims. A few are self-employed, providing medical transcription services.
Most successful medical record technicians are graduates of two-year accredited programs. Graduates of these programs should check with their schools’ placement offices for job leads. Those who have taken the accrediting exam and have become certified can use the AHIMA’s resume referral service.
You may also apply directly to the personnel departments of hospitals, nursing homes, outpatient clinics, and surgery centers. Many job openings are also listed in the classified advertising sections of local newspapers and with private and public employment agencies.
Medical record technicians may be able to achieve some advancement and salary increase without additional training simply by taking on greater responsibility in their job function. With experience, technicians may move to supervisory or department head positions, depending on the type and structure of the employing organization. Another means of advancing is through specialization in a certain area of the job. Some technicians specialize in coding, particularly Medicare coding or tumor registry. With a broad range of experience, a medical record technician may be able to become an independent consultant. Generally, technicians with an associate’s degree and the RHIT designation are most likely to advance.
More assured job advancement and salary increase come with the completion of a bachelor’s degree in medical record administration. The bachelor’s degree, along with AHIMA accreditation, makes the technician eligible for a supervisory position, such as department director. Because of a general shortage of medical record administrators, hospitals often assist technicians who are working toward a bachelor’s degree by providing flexible scheduling and financial aid or tuition reimbursement.
The salaries of medical record technicians are greatly influenced by the location, size, and type of employing institution, as well as the technician’s training and experience. According to the AHIMA, beginning technicians with an associate’s degree can earn between $20,000 to $30,000 annually. Those who have earned a bachelor’s degree can expect to earn between $30,000 and $50,000 a year. With five years of experience, technicians can earn up to $75,000 annually.
According to the U.S. Department of Labor, the median annual earnings of medical records and health information technicians were $26,110 in November 2004. Salaries ranged from less than $18,080 to more than $42,360.
In general, medical record technicians working in large urban hospitals make the most money, and those in rural areas make the least. Like most hospital employees, medical record technicians usually receive paid vacations and holidays, life and health insurance, and retirement benefits.
Medical records departments are usually pleasantly clean, well-lit, and air-conditioned areas. Sometimes, however, paper or microfilm records are kept in cramped, out-of-the-way quarters. Although the work requires thorough and careful attention to detail, there may be a constant bustle of activity in the technician’s work area, which can be disruptive. The job is likely to involve frequent routine contact with nurses, physicians, hospital administrators, other health care professionals, attorneys, and insurance agents. On occasion, individuals with whom the technicians may interact are demanding or difficult. In such cases, technicians may find that the job carries a high level of frustration.
A 40-hour workweek is the norm, but because hospitals operate on a 24-hour basis, the job may regularly include night or weekend hours. Part-time work is sometimes available.
The work is extremely detailed and may be tedious. Some technicians spend the majority of their day sitting at a desk, working on a computer. Others may spend hours filing paper records or retrieving them from storage.
In many hospital settings, the medical record technician experiences pressure caused by a heavy workload. As the demands for health care cost containment and productivity increase, medical record technicians may be required to produce a significantly greater volume of high-quality work in shorter periods of time.
Nonetheless, the knowledge that their work is significant for patients and medical research can be personally very satisfying for medical record technicians.
Medical Record Technician Career Outlook
Employment prospects through 2014 are excellent. The U.S. Department of Labor predicts that employment in this field will grow much faster than the average. The demand for well-trained medical record technicians will grow rapidly and will continue to exceed the supply. This expectation is related to the health care needs of a population that is both growing and aging and the trend toward more technologically sophisticated medicine and greater use of diagnostic procedures. It is also related to the increased requirements of regulatory bodies that scrutinize both costs and quality of care of health care providers. Because of the fear of medical malpractice lawsuits, doctors and other health care providers are documenting their diagnoses and treatments in greater detail. Also, because of the high cost of health care, insurance companies, government agencies, and courts are examining medical records with a more critical eye. These factors combine to ensure a healthy job outlook for medical record technicians.
Opportunities will be best in offices of physicians, particularly in large group practices, nursing care facilities, home health care services, and outpatient care centers.
Technicians with associate’s degrees and RHIT status will have the best prospects, and the importance of such qualifications is likely to increase.