How to Become a Medical Records Technician
A medical records technician (MRT) occupies one of the few positions in healthcare requiring no hands-on patient care, yet it is one of the most important jobs in the industry. Health care providers rely on the information in a patient’s medical records in order to diagnose and treat the patient successfully. The medical records technician plays a vital role in properly maintaining these records of patient medical history.
Every day, people make tens of thousands of visits to doctors and hospitals across the country, and each one of these visits involves a patient’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 – now more commonly referred to as a health information technician (HIT) – 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. A career as a medical records technician provides an excellent opportunity for detail-oriented individuals who enjoy the privilege and responsibility of ensuring top quality care without the patient contact that most healthcare positions require.
The focus is shifting from paper-based medical records to electronic health records (abbreviated as EHR). Technological advances are creating more challenging practices around the areas of access, privacy and security, quality, analytics, reimbursement and clinical documentation improvement. Because of the significant growth in technological advancements with information management, there are many opportunities and roles for an HIM professional.
For the medical records technician, the most common work environment is in a hospital setting. These individuals usually work in roles that ensure the quality of the medical record is complete and accurate. Where paper charts are still utilized, technicians may be involved in scanning and indexing the paper documentation so that it can be displayed correctly in electronic form. When there are discrepancies or deficiencies in the documentation, they will work with professional staff such as physicians and clinicians to ensure the documentation is complete and accurate.
Another common role for the technician is often the specialization of coding diagnosis and procedures based on the care a patient received so that the organization can be reimbursed for those services. This is known as coding. Coding is used not only for reimbursement but also for research and various registries for data reporting and trending.
In addition to hospital settings, MRTs are also employed in other areas where health information is used, like insurance companies, software vendors, pharmaceutical companies, physician practices, rehabilitation centers, home healthcare agencies, nursing homes, and government agencies.
Aspiring medical records technicians should enroll in a two-year associate degree program, making sure that the program is accredited by the Commission on Accreditation for Health Informatics and Information Management (CAHIIM).
While still in high school, students with an interest in this career can prepare by taking classes in health science subjects such as biology and human health, while also taking classes in computers, math and business. Many vocational schools now offer programs to help young people explore the growing field of health information management. There are also opportunities to take online courses to assist the student with preparation for work in this field.
There are numerous junior college programs in medical records technology, though they sometimes appear under slightly different names such as “health information technology.” Again, make sure that the program is accredited by CAHIIM. 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 doctor’s spoken notes (dictation) 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. There are many certification opportunities available through the American Health Information Management Association, which provides additional training resources – more details below!
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 AHIMA. Being credentialed by AHIMA opens the door for career advancement, thus improving salary earnings potential, enabling better networking with peers in similar roles, and assisting with lifelong learning through continuing education.
Additional certifications can be obtained from AHIMA in order to increase individual marketability. These include specialized certifications for coding (CCS/CCS-P), healthcare privacy and security (CHPS), tumor registry (CTR), health data analysis (CHDA), and EHR Credentialing (HIT Pro).
Necessary Skills and Qualities
The best medical records technicians tend to have a natural attention to detail, gaining satisfaction by seeing loose ends tied up in an organized way. Because health information is 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 technician must exercise his or her 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 of the MRT.
Opportunities for Advancement
To maintain the designation of RHIT, AHIMA requires 20 hours of continuing education every 2 years. As medical records technicians gain experience and additional training, there will be opportunities for promotions and raises, especially in larger medical settings such as hospitals or large practice groups. MRTs who show an inclination for lifelong learning, along with the appropriate tact and decorum, will have the best opportunity to advance into supervisory positions.
If you would like to gain the necessary education to become a medical records technician, we highly recommend that you check out our free School Finder Tool located HERE.
Salary and Job Outlook
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Salaries vary depending on education, experience and geographical location. According to the Bureau of Labor Statistics, medical records technicians make an annual median salary of $37,110; the bottom 10% earn a median of $24,190 and the top 10% earn a median of $61,400. MRTs who have gained experience with electronic health records generally command higher salaries, as do those with solid coding skills. Jobs with hospitals and the government generally pay better than jobs in doctor’s offices or extended care facilities.
The Bureau of Labor Statistics expects employment of medical records technicians to increase by 15% between 2014 and 2024, which is significantly faster than the average for all occupations. So what is causing this huge growth? Experts say that the aging of the U.S. population is increasing demand for all types of medical services. The emergence of electronic health records has also created new opportunities for MRTs with strong computer skills.
Also, check out our Health Careers page for more career guides.