Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians organize and evaluate these records for completeness and accuracy.

Technicians assemble patients’ health information. They make sure that patients’ initial medical charts are complete, that all forms are completed and properly identified and signed, and that all necessary information is in the computer. They regularly communicate with physicians and other health care professionals to clarify diagnoses or to obtain additional information.

Some medical records and health information technicians specialize in coding patients’ medical information for insurance purposes. Technicians who specialize in coding are called health information coders, medical record coders, coder/abstractors, or coding specialists. These technicians assign a code to each diagnosis and procedure. They consult classification manuals and also rely on their knowledge of disease processes. Technicians then use computer software to assign the patient to one of several hundred “diagnosis-related groups,” or DRGs. The DRG determines the amount for which the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the DRG system. In addition to the DRG system, coders use other coding systems, such as those geared toward ambulatory settings or long-term care.

Medical records and health information technicians will find job opportunities in hospitals, offices of physicians, nursing care facilities, outpatient care centers, and home health care services. Insurance firms that deal in health matters and public health departments also hire health information technicians to assist in data collection and research.

Employment of medical records and health information technicians is expected to grow much faster than average for all occupations through 2014 because of rapid growth in the number of medical tests, treatments, and procedures that will be increasingly scrutinized by health insurance companies, regulators, courts, and consumers.

Technicians with a strong background in medical coding will be in particularly high demand. Changing government regulations and the growth of managed care have increased the amount of paperwork involved in filing insurance claims. Additionally, health care facilities are having difficulty attracting qualified workers, primarily because of the lack of both formal training programs and sufficient resources to provide on-the-job training for coders.