When you enter a hospital, you see a whirl of white coats of physicians, nurses, radiologic technologists, and others. Every time these health care personnel treat a patient, they record what they observed and did to the patient. This record includes information the patient provides about their symptoms and medical history, and also the results of examinations, reports of X ray and laboratory tests, and diagnoses and treatment plans. Medical record technicians organize and evaluate these records for completeness and accuracy.
When assembling a patient's medical record, technicians, who may also be called medical record technicians, first make sure that the medical chart is complete. They ensure that all forms are present and properly identified and signed, and that all necessary information is on a computer file. Sometimes, they talk to physicians or others to clarify diagnoses or get additional information.
Technicians assign a code to each diagnosis and procedure. They consult a classification manual and rely, too, on their knowledge of disease processes. Technicians may then use a software program to assign the patient to one of several hundred diagnosis-related groups or DRG's. The DRG determines the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs that use the DRG system. Technicians who specialize in coding are called medical record coders, coder/abstractors, or coding specialists.
Technicians may also tabulate and analyze data to help improve patient care, to control costs, to be used in legal actions, or to respond to surveys. Tumor registrars compile and maintain records of patients who have cancer to provide information to physicians and for research studies.
Medical record technicians' duties vary with the size of the facility. In large to medium facilities, technicians may specialize in one aspect of medical records or supervise medical record clerks and transcribers while a medical record administrator manages the department (see the statement on health services managers elsewhere in the Handbook). In small facilities an accredited record technician may manage the department.
Medical record technicians may also be referred to as health information technicians.
Medical record technicians generally work a 40-hour week. Some overtime may be required. In hospitals where medical record departments are open 18-24 hours a day, 7 days a week, they may work on day, evening, and night shifts.
They work in pleasant and comfortable offices. Medical record technician is one of the few health occupations in which there is little or no contact with patients. Accuracy is essential, and this demands concentration and close attention to detail. Medical record technicians who work at video display terminals for prolonged periods may experience eyestrain and muscle pain.
Medical record technicians held about 76,000 jobs in 1992. About one half of jobs were in hospitals. Most of the remainder were in nursing homes, medical group practices, health maintenance organizations, and clinics.
In addition, insurance, accounting, and law firms that deal in health matters employ medical record technicians to tabulate and analyze data from medical records. Public health departments hire technicians to supervise data collection from health care institutions and to assist in research.
Some self-employed medical record technicians are consultants to nursing homes and physicians' offices.
Medical record technicians entering the field usually have formal training in a 2-year associate degree program offered at community and junior colleges. Courses include medical terminology and diseases, anatomy and physiology, legal aspects of medical records, coding and abstraction of data, statistics, databases, quality assurance methods, and computers as well as general education.
Technicians may also gain training through an Independent Study Program in Medical Record Technology offered by the American Health Information Management Association (AHIMA). Hospitals sometimes advance promising medical record clerks to jobs as medical record technicians, although this practice may be less common in the future. Advancement generally requires 2-4 years of job experience and completion of the hospital's in-house training program.
Most employers prefer to hire Accredited Record Technicians (ART). Accreditation is obtained by passing a written examination offered by the AHIMA. To take the examination, a person must be a graduate of a 2-year associate degree program accredited by the Committee on Allied Health Education and Accreditation (CAHEA) of the American Medical Association, or a graduate of the Independent Study Program in Medical Record Technology who has also obtained 30 semester hours of academic credit in prescribed areas. Technicians who have received training in non-CAHEA accredited programs or on the job are not eligible to take the examination. In 1992, CAHEA accredited 90 programs for medical record technicians.
Experienced medical record technicians generally advance in one of two ways by specializing or managing. Many senior medical record technicians specialize in coding, particularly Medicare coding or in tumor registry.
In large medical record departments, experienced technicians may become section supervisors, overseeing the work of the coding, correspondence, or discharge sections, for example. Senior technicians with ART credentials may become director or assistant director of a medical record department in a small facility. However, in larger institutions the director is a medical records administrator, with a bachelor's degree in medical record administration. (See the statement on health services managers elsewhere in the Handbook.)
Hospitals will continue to employ the most technicians. Most job openings will occur because of replacement needs. The job prospects for formally trained technicians should be very good. Employment of medical record technicians is expected to grow much faster than the average for all occupations through the year 2005 due to rapid growth in the number of medical tests, treatments, and procedures and because medical records will be increasingly scrutinized by third-party payers, courts, and consumers.
The need for detailed medical records in offices and clinics of doctors of medicine should translate into rapid growth in employment opportunities for medical record technicians in large group practices and offices of specialists. Rapid growth is also expected in health maintenance organizations, nursing homes, and home health agencies.
According to a 1992 survey of AHIMA members, accredited record technicans who worked as coders averaged $11.30 an hour; unaccredited coders averaged $9.77 an hour; and accredited record technicians in supervisory positions averaged $29,599 a year. The average annual salary for medical record technicians in the Federal Government in nonsupervisory, supervisory, and managerial positions was $22,008 in 1993.
Medical record technicians need a strong clinical background to analyze the contents of medical records. Other occupations that require a knowledge of medical terminology, anatomy, and physiology without directly touching the patient are medical secretaries, medical transcribers, medical writers, and medical illustrators.
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Reprinted with Permission of U. S. Department of Labor