Medical Records

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Medical Records Technology

[one_half][ads1][/one_half]A medical records technician (M.R.T) 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 M.R.T 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 person’s medical record. The doctor reviews a patient’s 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 patient’s 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.

Skill Required :

  • Ability to work long hours on computers.
  • Good stamina, patience & ability to understand medical terms.
  • Qualities of being good with people & working in a team are essential.

Subjects / Syllabus :

  • Introduction to Medical Record Science.
  • Medical Terminology.
  • Human Anatomy (in brief).
  • Physiology (in brief).
  • Pathology (in brief).
  • Pharmacology (in brief).
  • Principles of Hospital Management.
  • Public Health Structure in India.
  • Biostatistics in health science.
  • Computer science in hospital organization.

Eligibility & Admission Process :

10 + 2 Pass.

Colleges :

  • The Indira Gandhi National Open University – New Delhi.
  • Vardhman Mahavir Medical College – New Delhi.
  • University Of Delhi – New Delhi.
  • TGC Animation And Multimedia – New Delhi.
  • Indian Film and Television Institute – Meerut, Uttar Pradesh.
  • B G S Academy For Nursing Sciences – Mysore, Karnataka.
  • Sae India – New Delhi, Delhi.
  • Church of South India Hospital – Bangalore, Karnataka.

Job Prospects &  Salaries :

Nature of the work

Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions, and treatment out-comes. 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 technicians 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 technicians 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.

Some medical records technicians also use computer programs to tabulate and analyze data to improve patient care, control costs, provide documentation for use in legal actions, respond to surveys, or use in research studies. For example, cancer (or tumor) registrars maintain facility, regional, and national databases of cancer patients. Registrars review patient records and pathology reports, assign codes for the diagnosis and treatment of different cancers and selected benign tumors. Registrars conduct annual follow-ups on all patients in the registry to track their treatment, survival, and recovery. Physicians and public health organizations then use this information to calculate survivor rates and success rates of various types of treatment, locate geographic areas with high incidences of certain cancers, and identify potential participants for clinical drug trials. Cancer registry data also is used by public health officials to target areas for the allocation of resources to provide intervention and screening.

Medical records technicians’ and health information technicians’ duties vary with the size of the facility where they work. In large to medium-sized facilities, technicians might specialize in one aspect of health information or might supervise health information clerks and transcriptionists while a medical records and health information administrator manages the department. In small facilities, a credentialed medical records and health information technician sometimes manages the department.

To Employers :

The largest number of medical records technicians work in hospitals, according to the B.L.S. However, medical records technicians are employed by variety of health-care related businesses. In addition to hospitals, medical records technicians may work in private doctor offices, physical therapy offices, nursing homes, home health agencies, behavioral health centers, mental health centers, and other health-care-related service providers.