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A medical records technician (MRT) is one of the few positions in healthcare that does not include contact with patients and yet is one of the most important jobs in the industry. An MRT is responsible for entering patients’ medical records into a computer database so that they are accurate, up to date and accessible to those who need them at all times.
Every day, people make tens of thousands of visits to doctors and hospitals across the country, and each one of these visits involves a persons medical record. The doctor reviews a patients history as described in the medical record prior to or during a patient’s visit and then conveys in written or spoken notes the nature and content of the current visit. These notes detail symptoms, possible diagnoses and follow-up actions, such as prescribing medications or further testing.
A medical records technician transfers the data from a doctor’s notes into a patients permanent medical record, and the accuracy and timeliness of this data is all-important to appropriate patient treatment. The medical records technician position provides an excellent opportunity to detail-oriented individuals who enjoy the privilege and responsibility of ensuring top quality care without the patient contact that most healthcare positions require.
The medical records technician is typically a full-time position in an office environment. The specific details of these positions vary depending on the medical institution where the MRT is employed. Hospitals provide employment for 40% of all MRTs, while individual doctors offices and small clinics employ most of the remainder. The MRT must review medical records that contain a patient’s entire medical history, extract the significant details and enter them into a computer database. At the same time, the MRT also assigns codes for symptoms, diagnoses and clinical procedures the patient undergoes.
In practical terms, the MRT will work with one or a few different kinds of medical record and database software packages. The work is primarily computer-based, although an MRT also communicates with doctors and nurses to clarify any unclear items as needed about patient details or finding and delivering patient information to caregivers. In addition to medical settings, an MRT might also work for an insurance companys claims department or with a governmental agency or academic institution that analyzes health data.
Depending on the location and the quality of the local labor pool, you can be hired as an MRT with only a high school diploma or GED and then trained on the job. In the majority of cases, however, and especially in cities and larger medical operations, the prospective MRT should have an associates degree that includes courses in biology, anatomy, physiology, medical terminology and classes in business practices as well as the ethical and legal dimensions of the medical field. A bachelors degree is not necessary, although it is advantageous for those wishing to advance their careers to more supervisory positions.
There are numerous junior college programs in medical records technology, though they sometimes appear under slightly different names such as health information technology. The courses in these programs will cover details of the most widely used medical coding systems, database management and security, data analysis and insurance industry practices. MRTs may specialize in medical transcription, which is the transcribing of a doctors spoken notes into the computer. Another specialization is cancer registry, focused on recording details of the many types of cancer that exist and their treatments. There is a national cancer registry managed by the Centers for Disease Control (CDC) to which local registries contribute their data. This and other specializations may be acquired either during schooling, depending on the program, or on the job.
Licensing and/or Certification
Most employers prefer to hire registered or certified medical records technicians. The most common certification is as a Registered Health Information Technician (RHIT), gained by passing an examination administered by the American Health Information Management Association (AHIMA). Other certifications, such as the Certified Tumor Registrar (CTR), are offered by the American Academy of Coders and the National Cancer Registrars Association.
Necessary Skills and Qualities
The best MRTs tend to have a natural attention to detail, gaining satisfaction by seeing loose ends tied up in an organized way. Because medical records are confidential, MRTs are expected to have a high degree of ethical integrity, avoiding any inappropriate sharing of details. The job nearly always involves following established guidelines, typically under supervision, but there will be times when the MRT must exercise his own judgment to interpret certain notes and records. This will also involve careful communication with medical and business staff.
Most medical settings are quite busy, and everyone working in this environment must be patient and courteous while interacting with a wide variety of coworkers. The ability to stay focused in a fast-paced environment while maintaining close attention to detail and an efficient workflow are important qualities in an MRT.
Opportunities for Advancement
To maintain certification, MRTs must periodically take advantage of continuing education opportunities available through organizations such as the Board of Medical Specialty Coding and the Professional Association of Healthcare Coding Specialists (PAHCS). As an MRT gains experience and additional training, he will have opportunities for promotions and raises, especially in larger medical settings such as hospitals or large practice groups. An MRT who shows an inclination for lifelong learning, along with the appropriate tact and decorum, will have the best opportunity to advance into a supervisory position.
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