Nature of the Work

Medical records and health information management technicians assemble patients' health information, including medical history, symptoms, examination results, diagnostic tests, treatment methods, and all other healthcare provider services. They ensure the quality, accuracy, accessibility, and security of health information data. Technicians regularly communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain additional information.

The increasing use of electronic health records (EHR) will continue to broaden and alter the job responsibilities of health information management technicians. For example, technicians must be familiar with EHR computer software, maintain EHR security, and analyze electronic data to improve healthcare information. Technicians use EHR software to maintain data on patient safety, patterns of disease, and disease treatment and outcome.

Technicians can specialize in many aspects of health information. Some medical records and health information management technicians specialize in codifying patients' medical information for reimbursement purposes. They assign a code to each diagnosis and procedure by using classification systems software. The classification system determines the amount for which Medicare, Medicaid, or other insurance programs will reimburse healthcare providers.

Technicians also may specialize in cancer registry. Cancer (or tumor) registrars maintain facility, regional, and national databases of cancer patients. They review patient records and pathology reports, and assign codes for the diagnosis and treatment of different cancers and selected benign tumors. Technicians conduct annual follow-ups to track treatment, survival, and recovery. This information is used to calculate survivor rates and success rates of various types of treatment, to locate geographic areas with high incidences of certain cancers, and to identify potential participants for clinical drug trials.