Nature of the Work:
Just as schools and colleges keep transcripts of grades and employers maintain personnel records, doctors and hospitals set up a permanent file for every patient they treat. This file is known as the medical record or chart. It includes the patient's medical history, results of physical examinations, reports of X-ray and laboratory tests, diagnosis and treatment plans, doctors' orders and notes, and nurses' notes. The medical record shows what the patient's symptoms were, what tests were ordered, and how the patient responded to treatment
Accurate and orderly records are essential for clinical purposes, and have other important uses as well. They provide background and documentation for insurance claims and Medicare reimbursement, legal actions, professional review of treatment and medications prescribed, and training of health professions personnel. Medical records are used for research and planning as well. They provide data for clinical studies, evaluations of the benefits and cost of various medical and surgical procedures, and assessments of community health needs.
Managing an information system that meets medical, administrative, ethical, and legal requirements involves the teamwork of medical record administrators, medical record technicians, medical record clerks, and medical transcriptionists, known collectively as medical record personnel. Directing the activities of the medical record department is the medical record administrator, whose job it is to develop systems for documenting, storing, and retrieving medical information. Administrators train and supervise the medical record staff. They are responsible for compiling statistics required by Federal and State agencies, assist physicians in evaluations of patient care or research studies, and may testify in court about records and record procedures. Medical record administrators work closely with top hospital executives to monitor hospital spending and physician practice patterns.
Medical record technicians are the people who actually handle the records, organizing and evaluating them for completeness and accuracy. When assembling a patient's medical record, technicians first make sure that the medical chart is complete. With a paper medical record, this means ensuring that all forms are present and properly identified and signed.
Once they have all the necessary information, a process that may require them to contact physicians or nurses to fill in incomplete entries, technicians assign a code to each diagnosis and procedure documented in the record. In assigning codes, technicians consult a classification manual and rely, too, on their knowledge of disease processes. After the entries on the chart have been coded, technicians may use a packaged computer program to assign the patient to one of several hundred diagnosis-related groups or DRG's. The DRG determines the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs that use the DRG system. In large hospitals, technicians who specialize in the coding area are called medical record coders or coder/abstractors.
Since information in the medical record is used for reimbursement purposes as well as clinical decision making, it is doubly important that entries be complete and accurate. This has always been important for patient care; now it is important for the hospital as well. A coding error could mean a financial loss for the hospital since the amount of reimbursement may depend on the diagnostic group to which the patient is assigned.
Technicians have other duties as well. They may, for example, tabulate and analyze data at the request of hospital officials responsible for quality assurance, marketing, or planning. Technicians might be asked to tabulate statistics that show differences in the average length of a hospital stay according to diagnosis, admitting physician, and procedures performed. Technicians known as registrars maintain special registries showing occurrences of disease by type, such as cancer, injury, or stroke. Technicians also maintain health record indexes and compile administrative and health statistics for public health officials, administrators, planners, and others.
In response to inquiries from law firms, insurance companies, government agencies, researchers, and patients, medical record technicians may collect medical records. They may present these records during legal proceedings, for example, or provide documentation for meetings of oversight groups such as utilization review committees and medical review boards.
The day-to-day tasks of medical record personnel vary with the size of the facility. In a small facility, for example, a technician may have full responsibility for managing the medical record department, whereas in a large facility, technicians are likely to specialize in just one aspect of the work. If the department is large enough to employ medical record clerks and transcriptionists, a technician would be responsible for supervising and training them. In many nursing homes, a record clerk, working under a consultant who is a Registered Record Administrator (RRA) or an Accredited Record Technician (ART), is responsible for maintaining the medical record system.
Working Conditions:
Medical record personnel generally work a standard 40-hour week. Some overtime may be required. In hospitals where medical record departments are open 18-24 hours a day, 7 days a week, medical record personnel work on day, evening, and night shifts. Part-time work is generally available.
The work environment is usually pleasant and comfortable, but some aspects of the job can be stressful. The utmost accuracy is essential, and this demands concentration and close attention to detail. The emphasis on accuracy can cause fatigue and mental strain. Medical record technicians who work at video display terminals for prolonged periods may experience eyestrain and musculoskeletal pain.
Employment:
A majority of the medical record technicians' jobs are in hospitals. Most of the remainder are in medical group practices, health maintenance organizations, nursing homes, clinics, and other facilities that deliver health care.
In addition, insurance firms, accounting firms, and law firms that specialize in health matters employ medical record technicians to tabulate and analyze data from medical records. Public health departments hire technicians to supervise data collection from health care institutions and to assist in research.
Some medical record technicians provide services to nursing homes and physicians' offices on a consultant basis. Other self-employed record technicians specialize in coding, record copy services, or medical transcription, the typing of physicians' records and notes from dictating or recording equipment or, occasionally, from written notes.
Training, Other Qualifications, and Advancement:
Most employers prefer to hire a credentialed medical record technician. Gaining the credential as an Accredited Record Technician is voluntary and is obtained by passing a written examination offered by the American Medical Record Association (AMRA). To be eligible to take the examination, a person must be a graduate of a 2-year associate degree program accredited by the Committee on Allied Health Education and Accreditation of the American Medical Association in collaboration with AMRA, or a graduate of the Independent Study Program in Medical Record Technology who has also obtained 30 semester hours of academic credit in prescribed areas.
Medical record technology programs include courses in biological sciences, medical terminology, medical record science, business management, legal aspects, and introduction to computer data processing.
Experienced medical record technicians generally advance in one of three ways, by specializing, managing, or teaching. Many senior medical record technicians specialize in coding, particularly Medicare coding. Tumor registry is another specialty area.
Supervision and management offer a second way to advance. In large medical record departments, experienced technicians may become section supervisors, with responsibility for over-seeing the work of the coding, correspondence, or discharge sections, for example. Senior technicians may eventually be promoted to director or assistant director of medical record departments. Technicians who aim to become department heads should plan on satisfying the requirements for the Registered Record Administrator (RRA) credential, since employers generally prefer RRA's when filling the medical record director's job.
Teaching is another career option for experienced technicians. Qualifications vary from institution to institution, but most schools demand a master's degree in a related field, such as education or health administration.
Hospitals sometimes advance promising medical record clerks to jobs as medical record technicians, although this practice is becoming less common. Advancement generally requires 2-4 years of job experience and successful completion of the hospital's in-house training program.
Job Outlook:
Employment of medical record technicians is expected to grow much faster than the average for all occupations because of the pivotal role of medical records in managing health care costs. Management's heightened need for complete, accurate, and timely clinical data is the overriding reason for anticipated job growth. Office hours are expected to expand. Also contributing to projected growth are the likelihood of more detailed record analysis, shortened billing time, and increased contact with physicians and other hospital staff to clarify entries on the medical record and assure that the record is complete. Despite the rapid growth, most openings will occur because of replacement needs.
The key role of medical records in financial management is not the only reason for expecting employment to rise. Greater emphasis on documenting the quality of medical care, spurred in part by malpractice concerns, together with greater the skill required for documentation due to the complexity of medical records systems and the sensitivity of the information, will also spur demand. Relatively more technicians and fewer clerks will be used to staff medical departments.
Automation already has reduced the demand for medical record clerks by eliminating the need for labor-intensive tasks such as filing. Automation of this field has moved swiftly, and in many places it has reached a paperless state. Computerized systems currently in place enable transcriptionists to put physicians' and nurses' handwritten notes into machine-readable form; technicians using computers then retrieve and tabulate the necessary data.
The transcriptionist's role could be bypassed if direct entry of medical notes via bedside terminals or hand-held computers increases. While direct entry of medical records would lessen the demand for transcriptionists, technicians would still be needed to code the records. Direct entry is just now starting to be implemented, however, and it is hard to predict how rapidly it will be adopted.
Greater need for accurate and up-to-date medical records is not confined to the hospital sector. Health maintenance organizations, large medical group practices, nursing homes, and home health agencies share the need for complete and timely data for reimbursement purposes, professional review of the quality of care, and financial management The value of well-maintained medical records in financial management is likely to be an especially important consideration, given the for-profit orientation of many newly emerging health care facilities. This should fuel demand for medical record personnel in a variety of health care settings.
The outlook for experienced technicians who have completed a formal training program will be excellent through the year. Demand for experienced or credentialed technicians is expected to be very strong due to the emphasis on accuracy in coding and abstracting data. New graduates, too, are expected to encounter an extremely favorable job market
Jobseekers without formal training in medical record technology will probably not be hired as medical record technicians since highly accurate coding and abstracting skills are essential. Such individuals may be hired as medical record clerks, how-ever, with the prospect of promotion to positions as medical record technicians once they master the requisite skills.
Like other hospital employees, medical record personnel generally receive paid holidays and vacations, health insurance, life insurance, and retirement benefits.
Related Occupations:
Medical record technicians perform a variety of technical and clerical duties, including verification, transcription, and filing. Workers with similar duties include information clerks, insurance clerks, library technical assistants, medical secretaries, and medical transcriptionists.
