Every time a patient receives healthcare, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians organize and evaluate these records for completeness and accuracy.
Technicians begin to assemble patients’ health information by first making sure their initial medical charts are complete. They ensure that all forms are completed and properly identified and signed, and that all necessary information is in the computer. They regularly communicate with physicians or other healthcare professionals to clarify diagnoses or to obtain additional information.
Medical records and health information technicians assign a code to each diagnosis and procedure. They consult classification manuals and also rely on their knowledge of disease processes. Technicians then use computer 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. Technicians who specialize in coding are called health information coders, medical record coders, coder/abstractors, or coding specialists. In addition to the DRG system, coders use other coding systems, such as those geared towards ambulatory settings or long-term care.
Technicians also use computer programs to tabulate and analyze data to help improve patient care, to control costs, for use in legal actions, in response to surveys, or for use in research studies. Cancer registrars compile, maintain, and review records of cancer patients to provide information to physicians and for use in research studies.
Medical records and health information technicians’ duties vary with the size of the facility. In large to medium-sized facilities, technicians may specialize in one aspect of health information, or supervise health information clerks and transcriptionists while a medical records and health information administrator manages the department. (See the statement on medical and health services managers
elsewhere in the Handbook.) In small facilities, a credentialed medical records and health information technician sometimes manages the department.