What does a medical records technician do?

What is a Medical Records Technician?

Every day, people make thousands of visits to doctors and hospitals, and each one of these visits involves a person’s medical record.

A medical records technician is responsible for accurately transcribing and organizing patients' medical histories, symptoms and diagnoses, as well as categorizing treatments and procedures for insurance billing by assigning standard codes using a classification system.

The medical records technician position provides an excellent opportunity for detail-oriented individuals who enjoy the responsibility of ensuring top-quality care without the patient contact that most healthcare positions require.

What does a Medical Records Technician do?

Medical records technicians play a very important role in ensuring that physicians' offices, outpatient clinics and hospitals are organized and maintain detailed records of patients' visits, including symptoms, test results and medical histories.

A doctor reviews a patient’s history as described in the medical record before and during a patient's visit and then conveys either in written or spoken notes the nature and content of the current visit. The notes the doctor makes details the symptoms, possible diagnoses and follow-up actions, such as medications that are prescribed, or any further testing that may be required.

A medical records technician takes the data from a doctor's notes and transcribes them into a patient’s permanent medical record. The accuracy and timeliness of this data is part of health information management, and very important for appropriate patient treatment.

Medical notes may also be divided into specialities. For example, cardiology, gastroenterology, nephrology, neurology , pulmonology, or orthopedic care. This data can also be used for studies and research, public health programming, medical billing, by governments, private healthcare organizations, and public education.

A medical records technician will input and update information for doctors' and insurance companies' reference. Technicians will use a set of published codes used to categorize conditions, treatments and diagnoses for insurance processing. For example, they will use the International Classification of Diseases (ICD) or the Common Coding System for Healthcare Procedures (HCPCS).

Responsibilities of a medical records technician:
- Compiling patients' health information
- Communicating with doctors to explain diagnoses
- Ensuring patients' medical records are complete
- Entering information into a computer system
- Using a set of published codes on medical diagnoses and procedures
- Improving patient care and managing costs

What is the workplace of a Medical Records Technician like?

The medical records technician is typically a full-time position in an office environment. He or she can work in medical settings such as: hospitals, medical practices, clinics, and state or local health departments.