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- 176
- Medical Record Technicians
-
- (D.O.T. 079.362-014, -018)
-
- Nature of the Work
-
- When you enter a hospital, you see a whirl of white coats of
- physicians, nurses, radiologic technologists, and others. Every
- time these health care personnel treat a patient, they record what
- they observed and did to the patient. This record includes
- information the patient provides about their symptoms and medical
- history, and also the results of examinations, reports of X ray and
- laboratory tests, and diagnoses and treatment plans. Medical record
- technicians organize and evaluate these records for completeness and
- accuracy.
-
- When assembling a patient's medical record, technicians, who may
- also be called medical record technicians, first make sure that the
- medical chart is complete. They ensure that all forms are present
- and properly identified and signed, and that all necessary
- information is on a computer file. Sometimes, they talk to
- physicians or others to clarify diagnoses or get additional
- information.
-
- Technicians assign a code to each diagnosis and procedure. They
- consult a classification manual and rely, too, on their knowledge of
- disease processes. Technicians may then use a software 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. Technicians who specialize in
- coding are called medical record coders, coder/abstractors, or
- coding specialists.
-
- Technicians may also tabulate and analyze data to help improve
- patient care, to control costs, to be used in legal actions, or to
- respond to surveys. Tumor registrars compile and maintain records
- of patients who have cancer to provide information to physicians and
- for research studies.
-
- Medical record technicians' duties vary with the size of the
- facility. In large to medium facilities, technicians may specialize
- in one aspect of medical records or supervise medical record clerks
- and transcribers while a medical record administrator manages the
- department (see the statement on health services managers elsewhere
- in the Handbook). In small facilities an accredited record
- technician may manage the department.
-
- Medical record technicians may also be referred to as health
- information technicians.
-
- Working Conditions
-
- Medical record technicians generally work a 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, they may work
- on day, evening, and night shifts.
-
- They work in pleasant and comfortable offices. Medical record
- technician is one of the few health occupations in which there is
- little or no contact with patients. Accuracy is essential, and this
- demands concentration and close attention to detail. Medical record
- technicians who work at video display terminals for prolonged
- periods may experience eyestrain and muscle pain.
-
- Employment
-
- Medical record technicians held about 76,000 jobs in 1992. About
- one half of jobs were in hospitals. Most of the remainder were in
- nursing homes, medical group practices, health maintenance
- organizations, and clinics.
-
- In addition, insurance, accounting, and law firms that deal 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 self-employed medical record technicians are consultants to
- nursing homes and physicians' offices.
-
- Training, Other Qualifications, and Advancement
-
- Medical record technicians entering the field usually have formal
- training in a 2-year associate degree program offered at community
- and junior colleges. Courses include medical terminology and
- diseases, anatomy and physiology, legal aspects of medical records,
- coding and abstraction of data, statistics, databases, quality
- assurance methods, and computers as well as general education.
-
- Technicians may also gain training through an Independent Study
- Program in Medical Record Technology offered by the American Health
- Information Management Association (AHIMA). Hospitals sometimes
- advance promising medical record clerks to jobs as medical record
- technicians, although this practice may be less common in the
- future. Advancement generally requires 2-4 years of job experience
- and completion of the hospital's in-house training program.
-
- Most employers prefer to hire Accredited Record Technicians (ART).
- Accreditation is obtained by passing a written examination offered
- by the AHIMA. 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 (CAHEA) of the American
- Medical Association, 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. Technicians who have
- received training in non-CAHEA accredited programs or on the job are
- not eligible to take the examination. In 1992, CAHEA accredited 90
- programs for medical record technicians.
-
- Experienced medical record technicians generally advance in one of
- two ways by specializing or managing. Many senior medical record
- technicians specialize in coding, particularly Medicare coding or in
- tumor registry.
-
- In large medical record departments, experienced technicians may
- become section supervisors, overseeing the work of the coding,
- correspondence, or discharge sections, for example. Senior
- technicians with ART credentials may become director or assistant
- director of a medical record department in a small facility.
- However, in larger institutions the director is a medical records
- administrator, with a bachelor's degree in medical record
- administration. (See the statement on health services managers
- elsewhere in the Handbook.)
-
- Job Outlook
-
- Hospitals will continue to employ the most technicians. Most job
- openings will occur because of replacement needs. The job prospects
- for formally trained technicians should be very good. Employment of
- medical record technicians is expected to grow much faster than the
- average for all occupations through the year 2005 due to rapid
- growth in the number of medical tests, treatments, and procedures
- and because medical records will be increasingly scrutinized by
- third-party payers, courts, and consumers.
-
- The need for detailed medical records in offices and clinics of
- doctors of medicine should translate into rapid growth in employment
- opportunities for medical record technicians in large group
- practices and offices of specialists. Rapid growth is also expected
- in health maintenance organizations, nursing homes, and home health
- agencies.
-
- Earnings
-
- According to a 1992 survey of AHIMA members, accredited record
- technicans who worked as coders averaged $11.30 an hour;
- unaccredited coders averaged $9.77 an hour; and accredited record
- technicians in supervisory positions averaged $29,599 a year. The
- average annual salary for medical record technicians in the Federal
- Government in nonsupervisory, supervisory, and managerial positions
- was $22,008 in 1993.
-
- Related Occupations
-
- Medical record technicians need a strong clinical background to
- analyze the contents of medical records. Other occupations that
- require a knowledge of medical terminology, anatomy, and physiology
- without directly touching the patient are medical secretaries,
- medical transcribers, medical writers, and medical illustrators.
-
- Sources of Additional Information
-
- Information on careers in medical record technology, including the
- Independent Study Program, is available from:
-
- American Health Information Management Association, 919 N. Michigan
- Ave., Suite 1400, Chicago, IL 60611.
-
- A list of CAHEA-accredited programs for medical record technicians
- is available from:
-
- American Medical Association, Division of Allied Health Education
- and Accreditation, 515 N. State St., Chicago, IL 60610.
-