Medical Coding And Records

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Medical Records Technicians are the individuals responsible for assembling and maintaining the medical records of patients who receive health care. These records, which are vitally important in treating the patient, contain a compilation of the following information:

• Medical history
• Observations
• Surgical interventions
• Treatment outcomes
• Descriptions of symptoms
• Results of examinations
• Reports of x-rays and MRIs
• Results of laboratory tests
• Diagnoses
• Treatment plans

Technicians verify the completeness of a patient's initial medical chart and make sure that all forms are properly filled out and authenticated. They regularly consult with physicians and other health care professionals for clarification of patient diagnoses and to obtain any additional information required for a patient's records. Technicians also tabulate data for future analysis, provide documentation when needed for use in legal actions, and compile information used to classify reimbursement status of medical procedures by insurance companies.

Responsibilities

Medical records technicians organize and maintain patient records in a manner consistent with the requirements of all components of the health care system: medical, administrative, regulatory, legal, and ethical. A partial list of their duties includes the following:

• Process patient admission and discharge documents
• Review records for accuracy, completeness, and compliance with regulations
• Enter data into computers regarding demographic characteristics, disease history, diagnoses, and treatments
• Release information to persons and agencies according to regulations
• Protect the security of medical records to ensure that confidentiality is maintained
• Develop health record indexes and storage and retrieval systems to collate information

The specific day-to-day duties of a medical records technician will vary with the nature of the facility for which he/she works. In small facilities, a credentialed medical records technician usually assumes a variety of technician duties which often includes management of a department. In larger or medium-sized facilities, there are usually several technicians and very often, each will specialize in one aspect of health information. In these types of settings, management duties are usually assumed by an administrator. Examples of specialists in this field include the following:

• Medical Record Coders specialize in coding patients' medical information for insurance purposes. Based on their knowledge of disease processes, these technicians assign a code to each diagnosis and procedure. They then utilize specialized computer software to classify the patient as belonging to one of several hundred "diagnosis-related groups" (DRGs). The DRG classification determines the amount of reimbursement the hospital will recover from the patient's medical insurance carrier or from Medicare to cover the cost of the procedure. Coders are also responsible for using a variety of coding systems other than DRG to enter classifications for other applications such as doctor visits, ambulatory settings, or long-term care.
• Cancer Registrars specialize in the registry of cancer patients. Based on reviews of a patient's records and pathology reports, they assign codes for the diagnosis and treatment of cancers and also certain benign tumors. Registrars will enter information into regional or national databases and then follow up by conducting annual checks on patients in the registry to track and/or update their treatment, survival, and recovery. Information in the registry is used by physicians and public health organizations for a number of reasons including the derivation of survivor and success rates of various types of treatment, identification of geographic areas having high incidences of certain cancers, and the targeting of potential participants for clinical drug trials.

Job Characteristics

Most medical records technicians work a standard 40-hour week, although some overtime may be required. Those who are employed in hospital settings are often required to work evening or night shifts and/or work on weekends, due to the fact that hospital health information departments are usually open around the clock seven days a week.

Technicians typically do their work in pleasant and comfortable office settings. Unlike their counterparts in most health-related occupations, technicians usually have little or no direct contact with patients. There is some degree of stress in the job due to the ongoing demands for accuracy and the need to pay close attention to detail. Also, technicians are susceptible to the types of discomforts commonly experienced by people who work at computer monitors for prolonged periods of time; notably muscular pain and eyestrain.

To be successful in this job, individuals need good communication skills in order to effectively interface with insurance companies and other establishments. Technicians also need to be detail-oriented and extremely diligent, as accuracy is essential to the job. To an increasing extent, proficiency with computer use is becoming an extremely valuable asset for this profession.

 

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