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Medical Records/Health Information Technician  What They Do

Just the Facts

Medical Records and Health Information Technicians Career Video

Compiles, processes, and maintains medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the heath care system. Processes, maintains, compiles, and reports patient information for health requirements and standards in a manner consistent with the healthcare industry’s numerical coding system.

This career is part of the Health Science cluster Health Informatics pathway.

A person in this career:

  • Protects the security of medical records to ensure that confidentiality is maintained.
  • Reviews records for completeness, accuracy, and compliance with regulations.
  • Retrieves patient medical records for physicians, technicians, or other medical personnel.
  • Assigns the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  • Processes patient admission or discharge documents.
  • Transcribes medical reports.
  • Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Resolves or clarifies codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.
  • Identifies, compiles, abstracts, and codes patient data, using standard classification systems.
  • Releases information to persons or agencies according to regulations.

Insider Info

Dig into the details and check out what people in this job have to say about their work.

Related Careers

Working Conditions and Physical Demands

People who do this job report that:

  • You would often handle loads up to 10 lbs., sometimes up to 20 lbs. You might do a lot of walking or standing, or you might sit but use your arms and legs to control machines, equipment or tools.
  • Work in this occupation involves using your hands to hold, control, and feel objects more than one-third of the time
  • Work in this occupation requires being inside most of the time
  • Sound and noise levels are loud and distracting
  • Work in this occupation involves making repetitive motions more than one-third of the time
  • Work in this occupation involves sitting more than one-third of the time

Working in this career involves (physical activities):

  • Seeing clearly up close
  • Identifying and understanding the speech of another person

Work Hours and Travel

  • Overtime work

Specialty and Similar Careers

Careers that are more detailed or close to this career:

  • Cancer Registrar -- Reviews and compiles data related to cancer and other tumors in patients in order to facilitate their research and treatment.
  • Clinical Data Specialist -- Gathers, analyzes and ensures the integrity of data collected in a clinical trial setting.
  • Health Informatics Specialist -- Created systems to acquire, store, maintain, and secure patient health data.
  • Medical Billing Specialist -- Turns verbal and written descriptions of illnesses, procedures, chronic and contagious diseases, and injuries into numerical codes used for billing.
  • Medical Claims Processor -- Responsible for reviewing a medical claim for accuracy and validity and to decide if the items billed fall within the insurance member's plan provisions.
  • Medical Transcriptionist -- Records and transcribes surgical proceedings, medical records and other reports requiring knowledge of medical terminology.
  • Medical Administrative Technician --