Medical Records and Health Information Specialists
Additional Information
Duties
Health information and medical records experts often perform the following:
- Examine patient records to make sure they're up to date, full, and accurate.
- Work with clinical databases and registries to organize and update data.
- Assigning clinical codes to facilitate insurance reimbursement and data analysis is made possible by categorization systems.
- Collect, store, analyze, retrieve, and report data electronically.
- Protect the privacy of patients' medical records.
This includes a thorough evaluation of the patient's history, symptoms, medical examination and test results as well as other information concerning the healthcare services offered to the patient. It depends on where they work and the size of their employer.
Even though medical records and health information experts do not directly care for patients, they frequently collaborate with registered nurses and other healthcare professionals. In these meetings, they seek clarification on diagnoses or more information from the workers in question.
Electronic health records (EHRs) software and EHR security and privacy standards are used by medical records and health information professionals to evaluate electronic data and enhance healthcare information.
Examples of medical records and health information experts include the following:
Patients' records and pathology results are reviewed by cancer registrars to ensure they are accurate and thorough. Classification codes are used to describe the diagnosis and treatment of malignancies and benign tumors. Annual follow-ups by cancer registrars allow them to keep tabs on patients' treatment, prognosis, and overall health. Patients' medical records are compiled and analyzed for research reasons, and cancer patient databases are maintained at the institution level, regionally, and on a nationwide scale.
Clinical and follow-up data is gathered by health information technicians (HITs). Requests for records and other legal requests are handled by these individuals. In addition, the health information management department's technologists give administrative assistance to their colleagues.
For patient treatment, population health statistics, and billing reasons, medical coders give the appropriate diagnostic and procedure codes to each patient. Preexisting diseases such as diabetes may be reviewed to ensure accurate coding of patient data. They also serve as a point of contact between patients, healthcare practitioners, and the financial departments of hospitals and clinics.
Education
Some occupations demand postsecondary education, while others require only a high school diploma or an equivalent.
Medical terminology, health data needs and standards, and categorization and coding systems are commonly taught in postsecondary certificate and degree programs in health information technology. Applicants who take high school courses in health, computer science, math, and biology might improve their chances of admission.
Bachelor's degrees in healthcare and associated, business, and psychology are some of the topics of study for medical records/health information experts.
Registration, Licenses, and Certifications
It's possible that employers prefer to recruit certified medical records and health information professionals, or that they anticipate new hires to get their certifications quickly once they start working. CPC, CCA, and RHIT certifications are all accessible to medical coding and health information experts (RHIT).
Candidates for some certificates must pass an exam in order to receive them. Others demand a diploma from a recognized college or university. Coding certificates sometimes require job experience in a coding environment. Specialists are often required to maintain their certifications and complete continuing education courses on a regular basis once they have been certified.
Certifying cancer registrars is a requirement in several states and hospitals. To become a Certified Tumor Registrar (CTR), you must complete a formal education program, get relevant experience, and then pass an exam to earn your certification.
Advancement
Higher certification programs or a bachelor's or master's degree in health information technology might lead to positions in medical and health services management for specialists who have completed these programs. Depending on the facility, different requirements may apply.
Qualities that are essential
Critical thinking abilities. To enter diagnoses into a patient's medical records, medical records and health information experts must analyze medical paperwork.
Focused on the smallest details. There must be no room for error when it comes to validating and coding patient data.
Integrity. To ensure patient confidentiality, medical records and health information experts must use caution and conduct themselves responsibly when working with patient data.
Personality traits. To be successful in the medical records and health information management field, one must be able to communicate effectively with doctors, accountants, and other health care employees.
Pay
Medical registrars, surgical assistants, healthcare practitioners and technical professionals, all other earned the median annual income of $51,840 in May 2020. If half of the people in a profession make more than the median wage, and half earn less, we say that the median wage is too high or too low. Between the lowest 10% and the highest 10% of earners, there was a wide range of incomes.
Job Projections
Medical records and health information professionals are expected to see a 9% increase in employment between 2020 and 2030, which is roughly the same rate of growth as the national average for all jobs.
