Medical records clerks and technicians assemble, analyze, code, abstract, report, and maintain medical records information in manual and automated records systems. They organize and check medical records for completeness, accuracy, and compliance with regulatory requirements.
When assembling a patient’s medical record, they first ensure the medical record is complete. With a paper medical record, this means that all documentation is present in appropriate format and sequence, identified, and signed. In a growing number of medical centers, the medical staff use computers rather than the traditional paper record to note patient care information. In these hospitals, technicians use their own computer terminals to retrieve information from the patient’s record in the hospital’s central computer. A few medical centers are developing larger patient care information systems using optical disks and satellite transmission of data from one facility to another.
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.
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.