The Medical Records and Health Technician are responsible to keep a record of the observations during any medical or surgical interventions.
Primary Objectives:
- The Medical Records and Health Technicians are expected to keep record of the interventions but also of the outcome of any procedures.
- The Medical Records and Health Technicians must also include any information given to them by the patient concerning their symptoms, medical history, the results of examinations, reports of x rays and laboratory tests, diagnosis, and treatment and accuracy.
- The Medical Records and Health Technician assembles the patient’s health information, making sure that patients’ initial medical charts are complete.
- The Medical Records and Health Technician is one of the few health care providers that do not always get to meet the patient.
- The Medical Records and Health Technician must have a strong background in medical coding which is provided by some Community Colleges and today even online schools teach this type of job career.
The most important thing that a Medical Records and Health Technician must be capable of doing is that of accuracy. The Medical Records and Health Care Technician communicates with the physicians and other health care professionals to clarify diagnosis or to obtain additional information. The Medical Records and Health Technicians use computers programs to tabulate and analyze data to improve patient care, better control cost, provide documentations for use in legal actions, or use in research studies. The duties of the Medical Records and Health Care Technician vary in accordance with the size of the facility that they are working at and the number of employee’s available to do some of the duties required. In large to mediums size facility the Medical Records and Health Care Technician might specialize in just one aspect of gathering and inputting information. In some facilities there are Technicians who specialize in coding and they are referred to as Health Information Coders, medical records coders, abstractors, or coding specialists. These Medical Records and Health Technicians assign a code to each diagnosis and procedure relying on their knowledge of disease processes. The Technicians then use classifications systems software to assign the patient to one of several hundred diagnosis-related groups, or DRGs. The DRG determines the amount for which the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the DRG system.
The coders may use other systems besides the DRG system such as those required for ambulatory settings, physician offices, or long-term care. The way the Medical Records and Health Technician code any treatment or test depends on the hospital or doctors’ offices getting paid properly. This is very important to the facility and to the patient. The wrong coding could lead to the patient getting billed for part of the service which could be very expensive. The most dangerous thing is that these codes stay with the patients records and in case of an emergency the wrong code could prove to be deadly or at least cause the patient some harm. The importance of the coding job goes without saying is very essential to both the patient and the care giver. The insurance companies also play a part in the need for proper coding because without the right coding the insurance company won’t pay the bill or ends up paying out too much on a bill. This is one of the reasons that the cost of medical bills can go to high. The Important part of being a Medical Records and Health Technician is to help keep the cost of medical care down by using the right coding on any diagnosis or treatment involved with a patient.
The Medical Records and Health Care Technician must have taken at least a two year associate degree program accredited by Commission on Accreditation for Health Informatics and Information Management Education Technicians. In 2007 there were 245 CAHIIM accredited programs in Health Informatics and Information Management Education. The Medical Records and Health Technician must have good communication skills, great accuracy skills and be proficient on the use of computer programs. When the Medical Records and Health Technician has enough education, been certified and has had at least two years experience in the field they are able to move up gaining more prestige.