Medical Office Manager

Medical records and health information technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security in both paper and electronic systems. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.

All technicians document patients’ health information, including the medical history, symptoms, examination and test results, treatments, and other information about healthcare provider services. Medical records and health information technicians’ duties vary with the size of the facility in which they work.

Medical records and health information technicians typically do the following:

• Review patient records for timeliness, completeness, accuracy, and appropriateness of health data
• Organize and maintain data for clinical databases and registries
• Track patient outcomes for quality assessment
• Use classification software to assign clinical codes for reimbursement and data analysis
• Electronically record data for collection, storage, analysis, retrieval, and reporting
• Protect patients’ health information for confidentiality, authorized access for treatment, and data security

Although medical records and health information technicians do not provide direct patient care, they work regularly with physicians and other healthcare professionals. They meet with these workers to clarify diagnoses or to get additional information to make sure that records are complete and accurate.

The increasing use of electronic health records (EHRs) will continue to change the job responsibilities of medical records and health information technicians. Technicians will need to be familiar with, or be able to learn, EHR computer software, follow EHR security and privacy practices, and analyze electronic data to improve healthcare information as more healthcare providers and hospitals adopt EHR systems.