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Medical Records Technicians
Significant Points
  • Employment is expected to grow much faster than the average.
  • Job prospects should be very good, particularly for technicians with strong computer software skills.
  • Entrants usually have an associate degree.
  • This is one of the few health-related occupations in which there is no direct hands-on patient care.
Nature of the Work

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.

Work environment. Medical records and health information technicians work in pleasant and comfortable offices. This is one of the few health-related occupations in which there is no direct hands-on patient care.

Medical records and health information technicians usually work a typical 40-hour week. Some overtime may be required. In health facilities that are open 24 hours a day, 7 days a week, technicians may work day, evening, and night shifts. About 14 percent of technicians worked part-time in 2008.

Medical Records Technician, GS-0675-05

You need to have:

Knowledge of, and skill in applying, general rules and regulations of the medical facility, its personnel, and its functions, and automated data processing methods sufficient to:

  • search and abstract medical data;
  • review records for compliance with applicable medical facility and JCAHO standards;
  • analyze and evaluate patient medical records for completeness and consistency;
  • determine the correct code to assign to each diagnosis/operation and/or selected procedure;
  • request information pertaining to follow up of consultations, laboratory and other contracted services from within the medical facility, and from other health care facilities to complete patient records; and
  • participate in quality assurance duties that include review, analysis, and filing reports reflecting inpatient medical records data.
  • Medical Records Technician, GS-0675-06

    You need to have:

    Knowledge of, and skill in applying, general rules and regulations of the medical facility, its personnel, and its functions, and automated data processing methods sufficient to:

  • analyze the consistency of medical records involving a wide range of diseases, and medical and surgical procedures;
  • ensure that each medical record contains appropriate documentation to support the principal diagnosis, principal procedure, qualifying complications, and co-morbidities;
  • consult with medical staff for clarification and additional required information;
  • maintain special registries/databases of trauma or tumor patients treated at the medical facility;
  • review requests for release of information from the medical record by interpreting and applying the Privacy Act and other applicable guidelines;
  • Determines what records are to be archived and retired. Ensures proper sequencing in terminal digit order and separates records by patient category depending upon the designated retention period specified in applicable regulations;
  • Recognizes inconsistencies in medical records, and applies prescribed procedures to correct errors; and
  • Analyzes each request to ensure that proper authorizations are submitted and determines the originator’s entitlement to information in accordance with the Privacy Act and medical facility regulations. Retrieves records, compiles and collates medical data, and coordinates the release of medical records data with various medical and administrative staff members.
  • Medical Records Technician, GS-0675-07

    You need to have:

    Knowledge of, and skill in applying, general rules and regulations of the medical facility, its personnel, and its functions, and automated data processing methods sufficient to:

  • carry out specialized assignments;
  • set up special registries;
  • compile and complete various special and recurring reports;
  • implement and monitor internal quality assurance programs;
  • assist administrative or clinical personnel in the completion of special research studies;
  • code highly technical and diversified diagnoses, operations, procedures, and other medical and demographic data;
  • serve as a resource person for coding and abstracting problems;
  • train new employees and resolve problems encountered;
  • Translates the primary diagnosis, complications, co-morbid conditions, and principal and secondary procedures into International Classification of Diseases codes. Identifies, sequences, codes, and abstracts the data;
  • Resolves medical records problems and issues that are critical to the selection of the correct Diagnostic Related Group; and
  • Analyzes Emergency Room medical trauma records for pertinent information related to type of injury or extent of disability, diagnosis, medication prescribed, and procedure performed for inclusion in the Trauma Registry database. Develops accurate and meaningful statistical data. Identifies, analyzes, and resolves medical records problems and issues.
  • Training, Other Qualifications, and Advancement

    Entry-level medical records and health information technicians usually have an associate degree. Many employers favor technicians who have a Registered Health Information Technicians (RHIT) credential.

    Education and training. Medical records and health information technicians generally have an associate degree. Typical coursework in health information technology includes medical terminology, anatomy and physiology, health data requirements and standards, clinical classification and coding systems, data analysis, healthcare reimbursement methods, database security and management, and quality improvement methods. Applicants can improve their chances of admission into a postsecondary program by taking biology, math, chemistry, health, and computer science courses in high school.

    Certification and other qualifications. Most employers prefer to hire credentialed medical record and health information technicians. A number of organizations offer credentials typically based on passing a credentialing exam. Most credentialing programs require regular recertification and continuing education to maintain the credential. Many coding credentials require an amount of time in coding experience in the work setting.

    The American Health Information Management Association (AHIMA) offers credentialing as a Registered Health Information Technicians (RHIT). To obtain the RHIT credential, an individual must graduate from a 2-year associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and pass an AHIMA-administered written examination. In 2008, there were more than 200 CAHIIM-accredited health information technology colleges and universities programs.

    The American Academy of Professional Coders (AAPC) offers coding credentials. The Board of Medical Specialty Coding (BMSC) and Professional Association of Health care Coding Specialists (PAHCS) both offer credentialing in specialty coding. The National Cancer Registrars Association (NCRA) offers a credential as a Certified Tumor Registrar (CTR). To learn more about the credentials available and their specific requirements, contact the credentialing organization.

    Health information technicians and coders should possess good oral and written communication skills as they often serve as liaisons between healthcare facilities, insurance companies, and other establishments. Candidates proficient with computer software and technology will be appealing to employers as healthcare facilities continue to adopt electronic health records. Medical records and health information technicians should enjoy learning, as continuing education is important in the occupation.

    Advancement. Experienced medical records and health information technicians usually advance their careers by obtaining a bachelor’s or master’s degree or by seeking an advanced specialty certification. Technicians with a bachelor’s or master’s degree can advance and become a health information manager. (See the statement on medical and health services managers for more information on health information managers.) Technicians can also obtain advanced specialty certification. Advanced specialty certification is typically experience-based, but may require additional formal education depending on the certifying organization.

    Job Outlook

    Employment is expected to grow much faster than the average. Job prospects should be very good; technicians with a strong understanding of technology and computer software will be in particularly high demand.

    Employment change. Employment of medical records and health information technicians is expected to increase by 20 percent, much faster than the average for all occupations through 2018. Employment growth will result from the increase in the number of medical tests, treatments, and procedures that will be performed. As the population continues to age, the occurrence of health-related problems will increase. Cancer registrars should experience job growth as the incidence of cancer increases from an aging population.

    In addition, with the increasing use of electronic health records, more technicians will be needed to complete the new responsibilities associated with electronic data management.

    Job prospects. Job prospects should be very good. In addition to job growth, numerous openings will result from the need to replace medical record and health information technicians who retire or leave the occupation permanently. Technicians that demonstrate a strong understanding of technology and computer software will be in particularly high demand.

    Earnings

    The median annual wage of medical records and health information technicians was $30,610 in May 2008. The middle 50 percent earned between $24,290 and $39,490. The lowest 10 percent earned less than $20,440, and the highest 10 percent earned more than $50,060. Median annual wages in the industries employing the largest numbers of medical records and health information technicians in May 2008 were:

    Federal Executive Branch $42,760
    General medical and surgical hospitals 32,600
    Nursing care facilities 30,660
    Outpatient care centers 29,160
    Offices of physicians 26,210
    Sources of Additional Information

    A list of accredited training programs is available from:

    • The Commission on Accreditation for Health Informatics and Information Management Education, 233 N. Michigan Ave, 21st Floor, Chicago, IL 60601-5800. Internet: http://www.cahiim.org

    For information careers and credentialing, contact:

    Information on obtaining Medical Records Technician positions with the Federal Government is available from the Office of Personnel Management through USAJOBS, the Federal Government's official employment information system. This resource for locating and applying for job opportunities can be accessed through the Internet at http://www.usajobs.gov or through an interactive voice response telephone system at (703) 724–1850 or  (703) 724–1850  or TDD (978) 461–8404 and   (978) 461–8404. These numbers are not toll free, and charges may result. For advice on how to find and apply for Federal jobs, download the Insider's Guide to the Federal Hiring Process” online here.

    Sources:

    • Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2010-11 Edition; and
    • Office of Personnel Management, Position Classification Standards.

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