What Does A Medical Records Technician Do?
Medical records technicians are professionals who are responsible for maintaining patient records and ensuring that they remain accurate and accessible only to those who are authorized to view them. They organize and file paper records if the hospital they are working in is still keeping paper documents. Many institutions, however, have already migrated to electronic health records. If this is the case, the job of medical records technicians also involves maintaining the accuracy and security of these databases. They must know how to use electronic health records software proficiently so that patient health records are maintained and kept secure.
Another responsibility of medical records technicians is to abstract and code diseases, procedures, operations and other clinical data by following standard classification systems. Codifying these data is important in facilitating claims for reimbursement as well as for analysis. Thus, these professionals must see to it that they review the codes in the classification systems they use to avoid making any mistakes which would potentially affect the patient’s insurance reimbursement claims or even the kind of medical treatment they receive.
One of the areas that medical records technicians can specialize in is the maintenance of a cancer registry. In this registry, they keep databases of cancer patients and assign codes that would identify the diagnosis of the cancers and tumors as well as the corresponding codes for the treatments that were administered. These databases will enable authorities to gather pertinent data, such as identifying places in the country which have more cases of a particular type of cancer, tracking treatments done and their corresponding recovery rates as well as computing the rates of survival of cancer patients. Cancer registries are also vital in identifying possible patients for clinical trials of drugs that are currently under development.
Accuracy and completeness is important in all patient health information records so that insurance reimbursements can be processed right away and collaboration among healthcare professionals can be facilitated. It is the responsibility of medical records technicians to check these patient health data for correctness. In the event that they find discrepancies in the information or data that isn’t provided, they immediately get in touch with the patient’s healthcare provider as well as the medical department concerned so that necessary information can be provided and entered into the portfolio.
If a new record needs to be created, medical records technicians need to first verify if the patient does not have an existing record in the hospital. They will then assign a new number to the patient’s record and coordinate with the office of the attending physician to verify the information before the record folder is finally made.
Medical records technicians must also maintain the security and confidentiality of patient health information data. They must ensure that unauthorized personnel cannot just access anyone’s file. If they suspect that a breach has occurred, they must inform their supervisor right away and undertake the necessary protective measures to contain the breach. It is also the job of medical records technicians to keep all patient health information data confidential since sharing these with people who are not authorized to view this information is a violation of the law.