Medical Records Technician Overview

Medical records and health information technicians, commonly referred to as health information technicians, organize and manage health information data by ensuring that it maintains its quality, accuracy, accessibility, and security in both paper files and electronic systems. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.

Health information technicians typically do the following:

• Review patients’ records for timeliness, completeness, accuracy, and appropriateness of data
• Organize and maintain data for clinical databases and registries
• Track patient outcomes for quality assessment
• Use classification software to assign clinical codes for reimbursement and data analysis 
• Electronically record data for collection, storage, analysis, retrieval, and reporting
• Maintain confidentiality of patients’ records

Health information technicians document patients’ health information, including their medical history, symptoms, examination and test results, treatments, and other information about healthcare services that are provided to patients. Their duties vary by employer and by the size of the facility in which they work.

Although health information technicians do not provide direct patient care, they work regularly with registered nurses and other healthcare professionals. They meet with these workers to clarify diagnoses or to get additional information to make sure that records are complete and accurate.

The increasing adaptation and use of electronic health records (EHRs) will continue to change the job responsibilities of health information technicians. Technicians will need to be familiar with, or be able to learn, EHR computer software, follow EHR security and privacy practices, and analyze electronic data to improve healthcare information, as more healthcare providers and hospitals adopt EHR systems.

Health information technicians can specialize in many aspects of health information. Some work as medical coders, sometimes called coding specialists, or as cancer registrars.

Medical coders typically do the following:

• Review patient information for preexisting conditions, such as diabetes
• Assign appropriate diagnoses and procedure codes for patient care, population health statistics, and billing purposes
• Work as a liaison between the health clinician and billing offices

Cancer registrars typically do the following:

• Review patients’ records and pathology reports to verify completeness and accuracy
• Assign classification codes to represent the diagnosis and treatment of cancers and benign tumors
• Conduct annual followups to track treatment, survival, and recovery
• Compile and analyze cancer patient information for research purposes
• Maintain facility, regional, and national databases of cancer patients

Health information technicians typically need a postsecondary certificate to enter the occupation, although some may need an associate’s degree. Certification is often required.

Postsecondary certificate and associate’s degree programs in health information technology typically include courses in medical terminology, anatomy and physiology, health data requirements and standards, classification and coding systems, healthcare reimbursement methods, healthcare statistics, and computer systems. Applicants to health information technology programs may increase their chances of admission by taking high school courses in health, computer science, math, and biology.

A high school diploma or equivalent and previous experience in a healthcare setting are enough to qualify for some positions, but most jobs for health information technicians require postsecondary education.

Analytical skills. Health information technicians must be able to understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records.

Detail oriented. Health information technicians must be accurate when recording and coding patient information.

Integrity. Health information technicians work with patient data that are required, by law, to be kept confidential. They must exercise caution and a strong sense of ethics when working with this information in order to protect patient confidentiality.

Interpersonal skills. Health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel.

Technical skills. Health information technicians must be able to use coding and classification software and the electronic health record (EHR) system that their healthcare organization or physician practice has adopted.

Most employers prefer to hire health information technicians who have certification, or they may expect applicants to earn certification shortly after being hired. A health information technician can earn certification from several organizations. Certifications include the Registered Health Information Technician (RHIT) and the Certified Tumor Registrar (CTR), among others.

Some organizations base certification on passing an exam. Others require graduation from an accredited program. Many coding certifications also require coding experience in a work setting. Once certified, technicians typically must renew their certification regularly and take continuing education courses.

A few states and facilities require cancer registrars to be licensed. Licensure requires the completion of a formal education program and the Certified Tumor Registrar (CTR) certification.

Health information technicians may advance to other health information positions by receiving additional education and certifications. Technicians may be able to advance to a position as a medical or health services manager after completing a bachelor’s or master’s degree program and taking the required certification courses. Requirements vary by facility.