Medical Records Technician
A medical records technician is a non-medical profession though they work in a medical setting. A medical records technician does not have anything to do directly with a patient’s condition, diagnosis, or treatment. A medical records technician is an administrative job which primarily involves clerical tasks and record keeping in an office setting.
The job involves developing medical histories of patients and keeping those records updated either electronically or on paper in addition to complying with the current healthcare standards and coding systems.
How to Become a Medical Records Technician
A high school diploma or equivalent can be sufficient to get a job as a medical records technician. However, most employers are beginning to require formal training or an associate’s degree that includes skills such as creating, managing, editing, and interpreting medical records. Also, knowledge of medical jargon and terminology would be important. Those with computer system knowledge, coding, medical classifications, standards, and insurance training also have a higher chance for employment.
No matter what route you take, according to Bureau of Labor Statistics (BLS) it has become an increase trend for employers to want you to get certified prior or during the first couple of weeks of employment. There are many training programs that are accredited such as the Registered Health Information Technician (RHIT) program – which gives licenses through the American Health Information Management Association (AHIMA). There is also the Certified Tumor Registrar (CTR) program, which gives certification from National Cancer Registrars Association (NCRA) and the American Academy of Coders.
The RHIT certification exam consists of 7 domains focusing on: revenue cycles, legal matters, quality assurance, information technology, compliance, coding and data analysis. It takes 3.5 hours and is comprised of 150 questions. You pass with a scale score of 300 out 400.
The CTR certification exam consist of 6 domains focusing on: data quality assurance, analysis and data usage, operations and management, cancer committee and conference, and activities of centralized registries. This exam is both open and closed book consisting of 235 questions within a 4.5 hour allotted time frame. It is also necessary to score 300 out of 400 on the scale to pass.
According to the data on AHIMA Commission website there were 5,537 certified RHIT in the United States in 2015. Therefore, proving the importance of getting certified.
Job Description of a Medical Records Technician
Whenever a patient sees a doctor, there are notes from the doctor that a Medical Records Tech must add to a patient’s record such as:
- the existing health conditions
- medical history of the patient
- diagnoses reports
- medications or treatments prescribed
- schedules of treatments
- subsequent recovery
All these details are maintained in reports generated by a medical records technician.
A medical records technician is responsible to track all aspects of a patient’s medical history and care received. The accuracy and quality of this recorded data will be pertinent for insurance company reimbursements for services rendered to the patients from your employer. Therefore, you should have high analytical, technical, and computer skills in addition to being detailed-oriented and having high integrity when entering this career field. You will be maintaining and accessing patient’s personal information, well-being, health procedures, and medical problems.
BLS reported that 38% of medical record technicians work in hospital settings in 2014 followed by physicians offices at 21%. Most work full time, and those who do work in facilities that are open 24 hours a day may have to work evening hours or night shifts.