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Medical records jobs
Question: I am going to be a senior in high school and did volunteer work at a hospital this summer. While I did not enjoy patient contact, I did like helping out in the medical records department. They liked me a lot too and want to hire me as a clerk. What is the job progression in medical records? What will I need to do to advance?
— Syd
Response: Typically, you would begin work as a medical records clerk, progress to medical records technician and eventually to accredited record technician.
Job Description
Medical records clerks may begin working with non-confidential material. They compile, verify, type, and file medical records. They may use a proprietary software system.
Clerks also type reports that include statistical data such as admissions, discharges, deaths, births and types of treatment. They review medical records for completeness. They check that all forms and signatures are present. They locate, sign out and deliver medical records.
Clerks may be asked to assist other workers with coding of records. Some clerks may be designated as charting clerks and post results of laboratory tests to records.
After two to four years of experience and completion of a hospital's in-house training program, clerks may qualify for the next step on the career ladder, medical records technician, also called health record technician.
Technicians generally review medical records for completeness. They abstract and code clinical data such as diseases, operations, procedures, and therapies using standard classification systems.
Technicians need to be skilled in evaluating health records and maintaining information storage systems. They must have knowledge of medical record keeping systems and procedures, medical terminology, anatomy, physiology, and government regulations, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The title of accredited record technician can lead to higher pay and more responsible positions and the possibility in the future of supervisory jobs. To become a medical record administrator you will need to complete an approved four-year college program.
Advancement
Experienced medical records and health information technicians usually advance in one of two ways: specializing or managing.
Many senior technicians specialize in coding, particularly Medicare coding, or in cancer registry. Most coding and registry skills are learned on the job.
Some schools offer certificates in coding as part of the associate degree program for health information technicians. However, there are no formal degree programs in coding.
Specialty area
Cancer Registrars (Tumor Registrars) interpret, abstract, and enter medical and demographic information into a national database of cancer patients. This information will be used in medical research and treatment.
These specialists code records by diagnosis, medical history, type of treatment, and results. They conduct follow-up on patients every year to update the records. They may conduct database searches for patients who may be eligible to participate in clinical trials of cancer treatments.
Many cancer registrars begin their careers as medical record technicians and learn through on-the-job training. Others attend a two-year specialized training program. Cancer registrars may obtain professional certification from the National Cancer Registrars Association (NCRA).
In 2005, there were eleven formal two-year certificate programs approved by the NCRA. Some schools and employers offer intensive 1- to 2-week training programs in either coding or cancer registry. Once coders and registrars gain some on-the-job experience, many choose to become certified. Certification in cancer registry is available from the NCRA.
Training Options and Costs
While you may be able to start as a clerk with just a high school education, most employers require one year of training and an AA degree to advance to a technician position. Community college courses in medical terminology, office practices, science, health, and mathematics are helpful and sometimes preferred by employers.
To advance to a technician position, you may need to become a Registered Health Information Technician (RHIT). To secure this designation you need to pass a written examination offered by the American Health Information Management Association (AHIMA).
To take the examination, you must graduate from a two-year associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). Technicians trained in non-CAHIIM-accredited programs or trained on the job are not eligible to take the examination.
The following are CAHIIM approved programs in the Los Angeles area:
Salary
In Los Angeles, medical records clerks earn $20,000 to $25,000 to start. Medical records technicians have beginning earnings of $30,000 to $35,000.
Employment Outlook
Above average growth is projected for this field. Almost all health care facilities have a medical records department. Hospitals are the primary employers for medical records technicians.
Federal regulation changes such as HIPAA privacy laws and the way medical payments are made also increase the need for complete and accurate medical records. This creates an increasing need for people knowledgeable about medical records.
Susan W. Miller, M.A., is a National Certified Career Counselor, a Certified Vocational Evaluation Specialist and holds diplomate status on the American Board of Vocational Experts. She heads California Career Services, a private practice career counseling firm in Los Angeles.
E-mail career questions you'd like answered in this column to info@californiacareerservices.com or visit California Career Services at www.californiacareerservices.com.
— Syd
Response: Typically, you would begin work as a medical records clerk, progress to medical records technician and eventually to accredited record technician.
Job Description
Medical records clerks may begin working with non-confidential material. They compile, verify, type, and file medical records. They may use a proprietary software system.
Clerks also type reports that include statistical data such as admissions, discharges, deaths, births and types of treatment. They review medical records for completeness. They check that all forms and signatures are present. They locate, sign out and deliver medical records.
Clerks may be asked to assist other workers with coding of records. Some clerks may be designated as charting clerks and post results of laboratory tests to records.
After two to four years of experience and completion of a hospital's in-house training program, clerks may qualify for the next step on the career ladder, medical records technician, also called health record technician.
Technicians generally review medical records for completeness. They abstract and code clinical data such as diseases, operations, procedures, and therapies using standard classification systems.
Technicians need to be skilled in evaluating health records and maintaining information storage systems. They must have knowledge of medical record keeping systems and procedures, medical terminology, anatomy, physiology, and government regulations, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The title of accredited record technician can lead to higher pay and more responsible positions and the possibility in the future of supervisory jobs. To become a medical record administrator you will need to complete an approved four-year college program.
Advancement
Experienced medical records and health information technicians usually advance in one of two ways: specializing or managing.
Many senior technicians specialize in coding, particularly Medicare coding, or in cancer registry. Most coding and registry skills are learned on the job.
Some schools offer certificates in coding as part of the associate degree program for health information technicians. However, there are no formal degree programs in coding.
Specialty area
Cancer Registrars (Tumor Registrars) interpret, abstract, and enter medical and demographic information into a national database of cancer patients. This information will be used in medical research and treatment.
These specialists code records by diagnosis, medical history, type of treatment, and results. They conduct follow-up on patients every year to update the records. They may conduct database searches for patients who may be eligible to participate in clinical trials of cancer treatments.
Many cancer registrars begin their careers as medical record technicians and learn through on-the-job training. Others attend a two-year specialized training program. Cancer registrars may obtain professional certification from the National Cancer Registrars Association (NCRA).
In 2005, there were eleven formal two-year certificate programs approved by the NCRA. Some schools and employers offer intensive 1- to 2-week training programs in either coding or cancer registry. Once coders and registrars gain some on-the-job experience, many choose to become certified. Certification in cancer registry is available from the NCRA.
Training Options and Costs
While you may be able to start as a clerk with just a high school education, most employers require one year of training and an AA degree to advance to a technician position. Community college courses in medical terminology, office practices, science, health, and mathematics are helpful and sometimes preferred by employers.
To advance to a technician position, you may need to become a Registered Health Information Technician (RHIT). To secure this designation you need to pass a written examination offered by the American Health Information Management Association (AHIMA).
To take the examination, you must graduate from a two-year associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). Technicians trained in non-CAHIIM-accredited programs or trained on the job are not eligible to take the examination.
The following are CAHIIM approved programs in the Los Angeles area:
- Charles R. Drew University of Medicine and Science
- 1731 East 120th Street
- Keck Building
- Los Angeles, CA 90059
- Degree Awarded: Accredited Associate (HIT) Program
- (323) 563-4800
- www.cdrewu.edu/cosh
- Keck Building
- Cypress College
- 9200 Valley View
- Cypress, CA 90630
- Degree Awarded: Accredited Associate (HIT) Program
- (714) 484-7283
- healthscience.cypresscollege.edu
- Cypress, CA 90630
- East Los Angeles College
- 1301 Avenida Cesar Chavez
- Monterey Park , CA 91754
- Degree Awarded: Accredited Associate (HIT) Program
- (323) 265-8650
- www.elac.edu
- Monterey Park , CA 91754
- Loma Linda University
- 1905 Nichol Hall
- Loma Linda, CA 92350
- Degree Awarded: Accredited Baccalaureate (HIA) Program
- (909) 558-1500
- admissions.sahp@llu.edu
- www.llu.edu
- Loma Linda, CA 92350
- California Health Information Association (CHIA)
- 1915 N. Fine Avenue Ste. 104
- Fresno, CA 93727-1510
- Phone: 559.251.5038
- Fax: 559.251.5836
- Publications: Careers & Colleges Program. Scholarship Information. Journal.
- www.californiahia.org
- info@californiahia.org
- Fresno, CA 93727-1510
Salary
In Los Angeles, medical records clerks earn $20,000 to $25,000 to start. Medical records technicians have beginning earnings of $30,000 to $35,000.
Employment Outlook
Above average growth is projected for this field. Almost all health care facilities have a medical records department. Hospitals are the primary employers for medical records technicians.
Federal regulation changes such as HIPAA privacy laws and the way medical payments are made also increase the need for complete and accurate medical records. This creates an increasing need for people knowledgeable about medical records.
— • —
Susan W. Miller, M.A., is a National Certified Career Counselor, a Certified Vocational Evaluation Specialist and holds diplomate status on the American Board of Vocational Experts. She heads California Career Services, a private practice career counseling firm in Los Angeles.
E-mail career questions you'd like answered in this column to info@californiacareerservices.com or visit California Career Services at www.californiacareerservices.com.
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