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 computer software 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 computers. 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 digital 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. For instance, cancer registrars maintain facility, regional, and national databases of cancer patients. These technicians also may prepare statistical reports and trend analyses for the use of medical researchers.
- Adult Day Care Coordinators
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