HS 100 Lesson 10 by t91ux5qV


									                                          Lesson 10

                              Medical Records Personnel


A medical record is a permanent document of the history and progress of one person's illness or
injury. It is made to preserve information of medical, scientific, legal, and planning value and is a
compilation of observations and findings recorded by the patient's physician and other
professional members of the medical team. The entries and reports originate at various points in
the hospital, clinic, nursing home, health center, or other health care facility. Through a network
of communications systems they are entered in the individual's patient record. This vital medical
profile constitutes the patient's unique medical history.

Just as schools and colleges keep transcripts of grades and employers maintain personnel records,
doctors and hospitals set up a permanent file for every patient they treat. This file is known as the
medical record or chart. It includes the patient's medical history, results of physical
examinations, reports of X-ray and laboratory tests, diagnosis and treatment plans, doctors' orders
and notes, and nurses' notes.

The medical record shows what the patient's symptoms are, what tests are ordered, and how the
patient responded to treatment. Accurate and orderly records are essential for clinical purposes.
However, medical records have other important uses as well. They provide background and
documentation for insurance claims and Medicare reimbursement, legal actions, professional
review of treatment and medications prescribed, and training of health professions personnel.
Medical records are used for research and planning purposes. They provide data for clinical
studies, evaluations of the benefits and cost of various medical and surgical procedures and
assessments of community health needs.


Managing an information system that meets medical, administrative, ethical, and legal
requirements involves the teamwork of medical record administrators, medical record
technicians, and medical record clerks, known collectively as medical record personnel.
Directing and controlling the activities of the medical record department is the medical record
administrator, whose job it is to develop systems for documenting, storing, and retrieving medical
information. Administrators train and supervise the medical record staff. They are responsible
for compiling documents required by Federal and State agencies, assist the medical staff in
evaluations of patient care or research studies, and may be required to testify in court about
records and record procedures.

Recent changes in the way hospitals are paid for the care they provide have thrust medical records
into the limelight in most hospitals. Increasingly, medical record administrators are viewed as
key members of the management tea, and they work closely with the finance department to
monitor hospital spending patterns.

Medical record technicians serve as technical assistants to the registered record administrator,
carrying out many technical activities within the record department. Technicians' duties vary
with the size of the institution in which they work. Medical record technicians are the people
who actually handle records, organizing and evaluating them for completeness and accuracy.
When assembling a patient's medical record, the technician ensures that all forms are present and
properly identified and signed.

In a growing number of hospitals the medical and nursing staffs use computers rather than the
written charts to record blood pressure readings, medication dosages, test results, and other
patient care information. In these hospitals, technicians use their own computer terminals to
retrieve information from the patient's chart in the hospital's central computer.

Once they have all the necessary information (a process that may require them to track down
physicians or nurses to fill in incomplete entries), technicians assign a code to each diagnosis and
procedure documented in the record. In assigning codes, technicians consult a classification
manual and rely on their knowledge of disease processes. After the entries on the chart have been
coded, technicians use a packaged computer program to assign the patient to one of several
hundred diagnosis-related groups, or DRGs. The DRG determines the amount the hospital will
be reimbursed if the patient is covered by Medicare or other insurance programs that use the DRG

Because information in the medical record is used for reimbursement purposes as well as clinical
decision-making, it is doubly important that entries be complete and accurate. This has always
been important for patient care; now it is important for the hospital as well. A coding error could
mean a financial loss for the hospital since the amount reimbursed may depend on the diagnostic
group to which the patient is assigned.

Technicians have other duties. They assist the administrative staff of the hospital by tabulating
and analyzing data from the medical records. Technicians may tabulate statistics that show
differences in the average length of a hospital stay according to diagnosis, admitting physicians,
and procedures performed. Some technicians maintain special registries showing occurrences of
disease by type, such as cancer, injury, or stroke. Technicians maintain health record indexes and
compile administrative and health statistics for public health officials, administrators, planners,
and others. In response to inquiries from law firms, insurance companies, government agencies,
researchers, and patients, medical record technicians assemble medical records for legal
proceedings or for meetings of oversight groups such as utilization review committees and
medical review boards.

The day-to-day tasks of medical record personnel vary with the size of the facility. In a small
facility, a technician may have full responsibility for managing the record department, whereas in
a large facility, technicians are likely to specialize in just one aspect of the work. If the
department is large enough to employ medical record clerks, a technician would be responsible
for supervising and training them. In many nursing homes a record clerk, working under a
consultant who is a registered record administrator (RRA) or an accredited record technician
(A.R.T.), is responsible for maintaining the medical record system.


Medical record personnel generally work a standard 40-hour week. Some overtime may be
required. In hospitals where medical record departments are open 18 to 24 hours a day, seven
days a week, medical record personnel work on day, evening, and night shifts. Part-time work is
generally available.
The work environment is usually pleasant and comfortable, but some aspects of the job can be
stressful. The utmost accuracy is essential, and this demands concentration and close attention to
detail. The emphasis on accuracy can cause fatigue and mental strain. Medical record
technicians who work at video display terminals for prolonged periods may experience eyestrain
and musculoskeletal pain.


Medical record technicians hold about 40,000 jobs. Three out of four jobs are in hospitals. Most
of the remainders are in medical group practices, HMOs, nursing homes, clinics, and other
facilities that deliver health care.

In addition, insurance firms, accounting firms, and law firms that specialize in health matters
employ medical record technicians to tabulate and analyze data from medical records. Public
health departments hire technicians to supervise data collection from health care institutions and
to assist in research. Manufacturers of medical record systems, services, and equipment employ
them to develop and market their products.
Some medical record technicians provide service to nursing homes and physicians' offices as
consultants. Other self-employed record technicians specialize in coding, record copy services,
or medical transcription, and type physicians' records and notes from dictating or recording
equipment, or occasionally, from written notes.


Most employers prefer to hire a credentialed medical record technician. Gaining the credential as
an accredited record technician is voluntary and is accomplished by passing a written
examination offered by the American Medical Record Association (AMRA). To be eligible to
take the examination, a person must be a graduate of a two-year associate degree program
accredited by the Committee on Allied Health Education and Accreditation of the American
Medical Association in collaboration with AMRA, or a graduate of the Independent Study
Program in Medical Record Technology who has obtained 30 semester hours of academic credit
in prescribed areas. Community and junior colleges offer about 100 accredited programs for
medical record technicians. Medical record technology programs include courses in biological
sciences, medical terminology, medical record science, business management, legal aspects, and
introduction to computer data processing.

Hospitals sometimes advance promising medical record clerks to jobs as medical record
technicians, although this practice is becoming less common. Advancement generally requires
two to four years of job experience and successful completion of the hospital's in-house training

The minimum educational program for a registered record administrator is a baccalaureate
degree, generally four years in length. Post baccalaureate degrees are usually one year. The pre-
professional curriculum includes studies in the humanities and behavioral, biological, and
physical sciences. The professional curriculum includes medical terminology, medical care
organizations, disease classifications, organization, supervision, health care statistics, and
principles of law, as well as advanced data processing systems.

Employment of medical record technicians is expected to grow much faster than the average for
all occupations through the year 2010 because of the pivotal role of medical records in managing
health care costs. Management's need for accurate clinical data for purposes of financial control
is the overriding reason for anticipated job growth. Nevertheless, most openings will occur
because of replacement needs.

Most job openings will be in hospitals where employment of medical record personnel is
expected to rise sharply. Office hours are expected to expand. Also contributing to projected
growth is the likelihood of more detailed record analysis, shortened billing time, additional
quality control and management efficiency measures, and increased contact with physicians and
other hospital staff to clarify entries on the medical record and ensure that the record is complete.

Greater needs for accurate and up-to-date medical records are not confined to the hospital sector.
Health maintenance organizations, surgicenters, medical group practices, nursing homes, and
home health agencies share the need for complete and timely data for reimbursement purposes,
professional review of the quality of care, and financial management. The value of well-
maintained medical records in financial management is likely to be an especially important
consideration, given the for-profit orientation of many newly emerging health care facilities. This
should fuel demand for medical record personnel in a variety of health care settings.

The outlook for experienced technicians who have completed a formal training program will be
excellent through the year 2010. Demand for experienced or credentialed technicians is expected
to be very strong due to the emphasis on accuracy in coding and abstracting data. New graduates,
too, are expected to encounter an extremely favorable job market. Graduates are reported to be in
great demand, and the number of people completing training programs is expected to fall short of
that needed to fill job openings.

Job seekers without formal training in medical record technology will probably not be hired as
medical record technicians since highly accurate coding and abstracting skills are essential. Such
individuals may be hired as medical record clerks; with the prospect of promotion to positions as
medical record technicians once they master the requisite skills.

The demand for medical record administrators is greatest in hospitals. Other areas of
employment are ambulatory and long-term care facilities, State health departments; professional
standards review organizations, government agencies, and private industry. Medical record
administrators interested in teaching may accept faculty positions in academic programs for
training medical record technicians.


Earnings of medical record administrators and technicians vary according to the locality. Medical
record administrators begin around $25,000 and go up to $40,000 or more. Beginning
technicians in hospitals and medical schools averaged $23,300, according to a national survey
conducted by the University of Texas Medical Branch. Experienced technicians may work up to
higher supervisory positions with corresponding pay increases, although registered record
administrators fill most positions. Like other hospital employees, medical record personnel
generally receive paid holidays and vacations, health insurance, life insurance, and retirement

Medical record technicians perform a variety of technical and clerical duties, including
verification, transcription, and filing. Workers with similar duties include information clerks,
insurance clerks, medical secretaries, and medical transcriptionists.

Medical record administrators perform a variety of duties including designing health information
systems; planning, controlling, and organizing medical record services; and serving in a collegial
relationship with physicians and other health team department managers. Their duties are similar
to health care administrators, health educators, and nursing administrators.


    Why is a medical record so important?

    Who has the responsibility of managing medical records?

    What is the main purpose of a Medical Record Administrator?

    What are the major job functions of Medical Record Technicians?

    What is DRG?

    What are the day-to-day tasks of a Medical Record Technician?

    How many jobs are held by Medical Record Technicians in the United States?

    What agency accredits Medical Record Administrators and Technicians?

    What are the minimum educational requirements for Medical Record Administrators and

    In what type of facility is the demand for Medical Records personnel the greatest?

    What are the average earnings of Medical Records Administrators and Technicians?

For further information on careers and curricula in medical records write to: American Medical
Record Association, 875 N. Michigan Ave., Suite 1850, Chicago, IL 60605

                             Medical Transcriptionist

As the health field continues to grow, so does the task of organizing and recording the large
volumes of medical data generated by this expansion. Medical transcriptionists are skilled
members of the medical record team, and play an important part in this activity.

The medical transcriptionist uses a word processor to transcribe technical dictation that is
reproduced on a tape or recording machine, or at times is in written form. The dictation consists
of medical reports describing diagnostic work ups, therapeutic procedures, and clinical
summaries that are essential parts of an individual's medical record. These data are channeled to
physicians or to other health care facilities involved with the medical care of the individual. The
preparation of complete and accurate medical records is vital for diagnosis and treatment and as a
source of information for use in health statistics, medical scientific research, and legal claims.


Medical transcriptionists are employed in many types of establishments, including public and
private medical clinics, hospitals, medical centers, extended care facilities, medical research
groups, and city and State health departments. They work in pharmaceutical houses, physicians'
offices, and public and private health organizations. Generally, transcriptionists work in pleasant
surroundings that are air-conditioned, quiet, and free of distractions.


Anyone considering this career should be a high school graduate or the equivalent and have the
ability to type at an average rate of speed. Completion of courses in science, health, mathematics,
anatomy, and office practice are useful, in addition to a sound understanding of spelling,
vocabulary, punctuation, and grammar. Other requirements include normal hearing ability in
order to use transcribing equipment and the ability to learn medical terminology in post high
school courses. One method of study to develop skills in this work is a correspondence course in
medical transcription offered by the American Medical Board Association. This course can be
taken as a home study or in-service training program, and a certificate is awarded upon successful
completion of the program. This certificate is considered to be a useful credential when applying
for openings in this field. Other methods of preparing for a career in this work include formalized
vocational or on-the-job training programs. Medical transcriptionists who develop added skills
through continuing education may advance to supervisory positions.

Employment prospects for medical transcription are favorable. The importance of medical
records in research and the growing use of computers to store and retrieve medical information
are expected to increase demand for workers to transcribe various medical reports. Detailed
information required by third-party payers such as insurance companies and Medicare should
cause some growth in this occupation.


Medical transcriptionists have median annual earnings of about $25,000. The middle 50 percent
earn between $21,060 and $31,470; the lowest paid 10 percent earn less than $17,060; and the
highest paid 10 percent earn more than $39,070. The two most common work sites for medical
transcriptionists are hospitals, paying an average of $23,500, and offices and clinics of medical
doctors, paying an average of $22,600.


    What kind of work is done by Medical Transcriptionist?

    In what kind of facilities does the Medical Transcriptionist work?

    What are the minimum educational requirements for a Medical Transcriptionist?

    What are the median annual earnings for a Medical Transcriptionist?

There are a number of workers that type, record information, and process paperwork. Among
these are administrative assistants, bookkeepers, receptionists, secretaries, and human resource
clerks. Other workers who provide medical and legal support include paralegals, medical
assistants, and medical record technicians.

                                   Medical Secretaries

Medical secretaries work in private medical offices, group practices, hospitals, clinics, and other
health facilities. Those who work in the hospital setting are sometime called ward clerks. Their
responsibilities are limited to administrative and clerical duties, and they are not trained to assist
physicians with clinical or laboratory tasks. Medical secretaries are primarily responsible for the
orderly, efficient operation of the office. Typical duties include keeping individual medical
records, taking simple medical histories, filling out insurance forms, and billing patients for
medical services. They schedule appointments for patients, arrange for patients to be
hospitalized, handle telephone inquiries, and act as receptionists for incoming patients. Medical
secretaries take dictation and type correspondence, reports, and manuscripts. In certain cases they
do bookkeeping, prepare financial records, and handle credit and collections for their employer.
Medical secretaries generally work in pleasant surroundings in modern medical offices. Their
work is often performed under pressure and requires patience and tact at all times in dealing with


Persons considering this career should be high school graduates or the equivalent, preferably with
courses in English, biology, and typing. A sound knowledge of spelling, punctuation, grammar,
and vocabulary are important. One or two-year programs in secretarial science, with a medical
option, are given by accredited vocational schools and junior and community colleges. Graduates
of one-year programs receive certificates; those in two-year programs are awarded the Associate
in Applied Science degree. While post high schools education is not required for all beginning
jobs in this field, it may be helpful in gaining initial employment and for job advancement.

In some cases, persons with secretarial experience in other fields prepare for this career by taking
medical terminology and related courses as part of a continuing education program. There are no
licensing requirements for this work. However, many medical secretaries apply on a voluntary
basis for certification. By passing a series of examinations administered by the National
Secretaries Association, medical secretaries are given the designation Certified Professional
Secretary (CPS). Employers regard this designation as a mark of competence in the field.


Employment prospects for qualified medical secretaries are expected to be quite favorable
through 2010. This outlook is based on increased public demand for health services; the
expansion of medical facilities, HMOs, and group medical practice; and broader insurance
covered by government-sponsored and private health insurance plans. Qualified medical
secretaries can advance to such positions as administrative assistant or office manager.


    What is the job description of a Medical Secretary?

    What are the minimal educational requirements for Medical Secretaries?

For further information contact: The National Secretaries Association, 301 E. Armour Blvd.,
Kansas City, MO 64111

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