Health Information Technicians

On the Job

Overview

Health information technicians collect, code, and maintain medical information about patients.

Many people visit the doctor once a year for a check-up. Your height and weight are measured. Your lungs are listened to, your heartbeats are counted, and your blood pressure is checked. The doctor asks you several questions about how you are feeling and if you are having any problems. But before any of this happens, you check in first to let the office know you are there. Your file is pulled and is reviewed by the nurse or doctor, often before they even step in the examination room. This way, the doctor can notice changes in your health, from weight gain to an improved resting heart rate.

Medical records include all information about patients' visits to hospitals or doctors. For example, records include patients' symptoms, medical history, and test results. They also contain x-rays, diagnoses, and treatment plans. Health information technicians gather and organize all this information. They make sure records are complete and accurate. They also develop organized filing and storage systems that make it easy to store and gather files. In addition, they make sure that files are secure and confidential. Occasionally technicians talk to physicians to get more information about patients, especially when files are missing important data.

Once records are organized, technicians enter some of the information into computers. For example, they enter the patient's age, gender, history and extent of disease, and treatment. Then technicians assign a code to each diagnosis and procedure. They consult a classification manual to find the proper code. Experienced technicians remember the codes. Next, technicians use a computer program to assign patients to a ¿diagnosis-related group,¿ or DRG. The DRG determines the amount of money a hospital receives from insurance companies.

Health information technicians may be responsible for giving patient records to lawyers and insurance companies. Some technicians maintain special records, called registries. These records are for specific groups of patients, such as those who have cancer, heart disease, or organ transplants. One specialty in this occupation is tumor registrar. These technicians collect and maintain records of patients who have cancer. They prepare reports about cancer patients, such as the number of patients with each type of cancer. Medical researchers and other medical staff use these reports. Tumor registrars also contact patients and their physicians. They gather information such as patients' survival rates. A second specialty in this field is diagnosis and procedure coding. Health information coders or coding specialists do only this type of work.

Health information technicians may also perform other related duties. These may include transcription, processing insurance bills, and handling patient admission and discharge forms. Experienced technicians may train or supervise other medical records staff.

Health information technicians are also called medical records technicians.

Work Activities

The following list of occupational tasks is specific to this career.

• Gather and organize information for patients' medical records.
• Process patient admission and discharge forms.
• Make sure medical records are secure and kept confidential.
• Review patients' medical records for completeness and accuracy.
• Talk to doctors and other health care workers to get more information.
• Enter information, such as diagnoses and treatments, from medical records into computers.
• Assign a code to each diagnosis and procedure, using standard coding systems.
• Use computers to assign patients to a ¿diagnosis-related group¿ (DRG).
• Create a filing and storage system to manage records and information. Maintain medical record indexes.
• Compile and maintain records of patients who have certain health problems. Analyze data to provide research information.
• Assemble and analyze patient data to help improve patient care or control costs.
• Prepare medical records for release to authorized parties.
• May specialize in coding diagnoses and procedures.
• May supervise and train other medical records staff.
• May bill insurance companies and prepare patients' invoices.
• May perform medical transcription.

People in this career perform the following list of tasks, but the tasks are common to many occupations.

• Get information needed to do the job.
• Use computers.
• Organize, plan, and prioritize work.
• Establish and maintain relationships.
• Evaluate information against standards.
• Communicate with supervisors, peers, or subordinates.
• Perform administrative tasks.
• Identify objects, actions, and events.
• Process information.
• Document and record information.
• Monitor events, materials, or surroundings.
• Make decisions and solve problems.
• Update and use job-related knowledge.
• Teach others.
• Analyze data or information.
• Resolve conflicts and negotiate with others.

Working Conditions

In a typical work setting, people in this career:

Interpersonal Relationships

• Have a high level of social contact. They regularly talk to doctors and insurance workers.
• Communicate by telephone and in person on a daily basis. They communicate less often by writing letters and e-mail.
• Often work in a group or as part of a team.
• Are sometimes placed in conflict situations. Insurance transactions are complex and patients may be denied a service.
• Are moderately responsible for outcomes and results.
• On occasion deal with angry, unpleasant, or discourteous people.

Physical Work Conditions

• Always work indoors.
• May sometimes be exposed to the diseases and infections of patients.
• Work very near others. They often share the same work space. In addition, file rooms may be small.

Work Performance

• Must be very exact in their work. Errors could have serious results. This is because medical records are used for research and to determine insurance payments.
• Make decisions that affect others on a weekly basis. They don't usually consult a supervisor before deciding a course of action, but for larger decisions, may seek advice first.
• Set most of their tasks and goals for the day without talking to a supervisor first.
• Abide by weekly deadlines.
• Often repeat the same physical activities, such as entering information or pulling files.

Hours/Travel

• May work part time or full time. Most work full time.
• Usually work a regular, set schedule.
• May work day, evening, or night shifts.

Physical Demands

In a typical work setting, people in this career:

People in this career frequently:

• Sit for long periods of time.
• Use hands to handle or control medical records, files, or computers.
• Repeat the same motions.

It is important for people in this career to be able to:

• See details of objects that are less than a few feet away.
• Use fingers to grasp, move, or assemble very small objects.
• Speak clearly so listeners can understand.
• Understand the speech of another person.

It is not as important, but still necessary, for people in this career to be able to:

• Use one or two hands to grasp, move, or assemble objects.
• See details of objects that are more than a few feet away.
• Hold the arm and hand in one position or hold the hand steady while moving the arm.
• Bend, stretch, twist, or reach out.
• Move two or more limbs together (for example, two arms, two legs, or one leg and one arm) while remaining in place.
• Use stomach and lower back muscles to support the body for long periods without getting tired.
• Focus on one source of sound and ignore others.
• See differences between colors, shades, and brightness.
• Hear sounds and recognize the difference between them.
• Make quick, precise adjustments to machine controls.
• Coordinate movement of several parts of the body, such as arms and legs, while the body is moving.
• Be physically active for long periods without getting tired or out of breath.
• Move arms and legs quickly.
• Use muscles to lift, push, pull, or carry heavy objects.