Learn something new every day
More Info... by email
A medical records technician maintains files, records and health related documents. He or she typically reports to the medical records administrator. His or her workplace may be a convalescent facility, medical clinic, hospital or medical practice that includes multiple medical practitioners.
Computerized records frequently comprise the bulk of what a medical records technician is normally expected to maintain. However, a significant number of important documents in her control are handwritten. These commonly include medical charts, liability release forms and patient or family communications with physicians or medical facilities.
Whether on a computer or in a hard copy file, a medical records technician is typically required to guarantee the accuracy of all patient information. He or she is customarily expected to update medical information on patients on a daily basis. This data normally includes details on medical procedures, medications, complications and referrals to other physicians or facilities. The accuracy of his or her work is especially important in processing medical insurance claims and vital to correctly treat the patient if he or she returns to the medical establishment.
In addition to patient record maintenance, a medical records technician is frequently required to keep files on topics that may affect funding or be important in medical research. This information generally pertains to the kinds and frequency of diseases treated at the facility. Recidivism rates for injuries and certain illnesses are also statistics frequently collected by a person in this job position.
In some health care settings, a medical records technician is required to transfer patient records into codes. This system generally simplifies the process of cross-indexing information on physicians, disease names and treatments. The purpose of this coding system is to make similar information readily available to physicians without having to pour over many files.
Discretion is an important asset for a person with this job. Medical files are highly confidential and are generally expected to be protected from outside sources. The files usually require storage in a secure place that is normally locked or equipped with an alarm. A medical records technician is typically expected to limit his or her discussion of patient files with the physician of record.
This position generally requires a high school diploma or equivalent. Most employers prefer training at a vocational or technical institute. Community colleges often offer associate degree programs in medical records technology. Some regions require a license or certificate to hold this position. Work experience in a medical environment is desirable to a significant number of potential employers.
@Azuza - Medical records and health information technicians generally must undergo a background check before being hired. Also there is a federal law called the Health Insurance Portability and Accountability Act that mandates how patients information can be used in a medical setting.
Generally in a health care setting health care workers are only allowed to share a patients information with those who need to know it. So for instance a nurse will share patient information with the doctor because the doctor needs it to treat the patient. But the nurse wouldn't be allowed to share the same information with say, the lab technician two floors down that isn't even working on that patients case.
HIPAA holds all health care workers to these same standards of confidentiality. This includes medical records technicians. They aren't allowed to share patient information with the public and could face legal consequences if they do so.
It sounds like a medical records clerk has a lot of responsibility and access to sensitive information. I hope medical facilities do thorough background checks on these people. What's to stop them from sharing patients info with the rest of the public?
One of our editors will review your suggestion and make changes if warranted. Note that depending on the number of suggestions we receive, this can take anywhere from a few hours to a few days. Thank you for helping to improve wiseGEEK!