A career in medicine can take many paths. Patient care is multifaceted, and medical records specialists use their skills to maintain information that keeps doctor’s offices, hospitals, clinics, and other facilities running smoothly.
Also called health information technicians, these professionals perform a variety of administrative support duties. They may enter information into medical systems, file paperwork, manage electronic documents, and ensure that patient records are always kept up to date.
If you are interested in an office job in the medical field, being a medical records specialist could be a good fit for you.
What Does a Medical Records Specialist Do?
Medical records specialists help hospitals and doctor’s offices maintain accurate patient data. Healthcare information is always being updated, and systems for keeping records are improving. Across the entire industry, trained medical records specialists provide invaluable support to keep healthcare facilities operating smoothly.
Some of their responsibilities include:
- Gathering, preparing, and filing patient exam charts
- Organizing and updating medical records and patient files
- Filing patient information into a secure electronic healthcare system
- Updating and sorting paper copies of patient documentation
- Verifying medical information across platforms and files
- Making copies, preparing records, and sending files per patient and physician requests
- Manage all Electronic Medical Records (EMR) for a facility
- Coordinate with physicians and billing departments to prepare patient records for insurance purposes.
The tasks you perform, as a medical records specialist, may vary depending on where you work. Medical records specialists have a broad choice of options. Some like to work with large quantities of data in hospitals; other prefer working in particular sectors, like a pediatric doctor’s office or nursing home.
There is also a need for trained medical records specialists in insurance companies and government healthcare. But regardless of where you ultimately choose to work, the skills you develop beforehand will allow you to perform your job well.
What Is an Easy Way to Become a Medical Records Specialist?
An easy way to qualify for a job as a medical records specialist is to complete a health information technician program at a vocational school. These programs teach you what you need to know about healthcare management and medical principles. Because the world of healthcare is digitizing rapidly, the need for professionals trained in the latest EHR platforms is growing.
What Do You Learn During a HIT Program?
A medical records specialist must know how to maintain records in a healthcare setting, but their skills are not limited to organization and bookkeeping. Because they must read, interpret, and confirm patient data, understanding medical terminology is important. Let’s take a closer look at what type of classes you can expect to take.
Anatomy and Physiology
Doctors report patient symptoms in medical terminology. Being able to understand various conditions and corroborate symptoms requires an understanding of how the human body works. Anatomy studies the structure of the body while physiology explores its systems.
Every part of the body works as part of a larger system. Knowing the most commonly used terms and their definitions is a fundamental aspect of a medical record specialist’s job.
In addition to learning about the human body itself, the health information technician program also teaches students medical terminology. Many terms that are not part of the everyday English language are commonplace in professional medical settings.
As someone who will work closely with records and reports, a medical records specialist must know exactly what doctors describe and how to appropriately file a patient’s information into an electronic system. Instead of memorizing terms, students learn how to take apart terms into their individual parts, including prefixes, suffixes, and roots.
Medical Principles and Foundations
This course covers the ethics of the healthcare world. Principles such as justice and autonomy are explored in the context of patient care. Although you may not provide any medical treatments, you still need to act ethically and in the best interest of patients. Understanding medical principles also helps a medical records specialist ensure that records are maintained in compliance with industry standards.
Intro to Pharmacology
Medications that patients take to manage symptoms will often show up on medical charts. A medical records specialist must understand the names of common prescription medications and their applications in healthcare. This introductory course to pharmacology explores how medications impact the human body. Students also learn important pharmacological terms they are likely to encounter in medical records.
Intro to Medical Insurance and Coding
Medical coding, also known as clinical coding, classifies health conditions and disorders with a universal code. These alphanumeric codes ensure an accurate billing process, and they allow for easier collaboration across multiple healthcare facilities.
Different codes tell insurance companies information like a patient’s diagnosis, what types of treatments they’ve received and any special circumstances that affect their diagnosis or their treatment options.
Medical records specialists must also understand the medical coding process. They should be able to identify information easily, confirm codes are accurate and update records as needed. During a health information technician program, students learn the different coding protocols that are used throughout the medical field, including ICD-10, CPT & HCPCS.
A medical records specialist speaks with colleagues to gather and verify details on their reports. Communication requires professionalism and confidentiality. Best practices include showing empathy, being responsive and using appropriate language to ensure patients fully understand what they are being asked. A medical records specialist must always act with decorum and recognize how a patient’s experiences and conditions affect their communication. Likewise, they should know how to ask the right questions in the proper manner to gather the most accurate information.
Collections and Reimbursement Procedures
Medical billing and payments can be a difficult and stressful process for patients. The collections and reimbursement procedures a facility takes must be done in accordance with legal and ethical standards.
During the health information technician program, students learn about how medical billing works, how facilities collect money from patients and how insurance companies reimburse losses to the healthcare company.
Intro to Medical Bookkeeping
At the heart of record maintenance lies good bookkeeping skills. A medical records specialist must know how to keep accurate data in accordance with medical law. HIPPA, or the Healthcare Insurance Portability and Accountability Act, establishes the laws that healthcare providers must follow to protect patients’ rights and identities.
Medical bookkeeping includes HIPPA compliance and technical skills. Students will learn how to use an Electronic Health Records (EHR) system, how to create, update and modify patient records.
ICD-10-CM coding is the standard American medical coding language. The codes found in the ICD-10 contain classifications for all health disorders and medical conditions recognized in the United States.
Diagnosis, symptoms, treatments, and medical procedures all have unique codes a medical records specialist should know. While you may not need to know all codes, you do need to understand how ICD-10-CM coding works and how to look up codes when needed.
Why Does a Medical Records Specialist Need to Know Anatomy?
You may not think working in an office requires extensive anatomical knowledge. It’s true that you won’t work in exam rooms or consult with patients to provide healthcare treatments. However, there are still many tasks a medical records specialist performs that require a strong knowledge of anatomy.
Completing insurance reimbursements and filing claims requires knowledge of human anatomy, medical conditions, and their respective medical codes. Entering codes into EHR systems requires a knowledge of anatomy. Rather than simply memorizing a code, medical records specialists must understand what each code denotes and how it affects a patient. This also helps deepen understanding and promote empathy.
Medical records specialists may also have to transcribe medical notes from doctors or nurses. To follow orders and avoid mistakes, you must be able to interpret any anatomical words you encounter.
Anatomy Terminology That a Medical Records Specialist Must Know
The types of terms a medical records specialist will encounter varies depending on where they work. For example, a medical records specialist in an oncologist’s office will encounter far more terminology about cancer than a specialist in a general practitioner’s clinic.
Anatomy is often used to describe the position, direction, and location of symptoms on a patient’s body. These are common terms that you may encounter on the job:
The term “anatomical position” refers to a patient standing straight with their arms at their sides. Their feet and palms face forward with the thumbs pointed away from the body. Anatomical position is an important starting point to reference other directions and positions on the body.
The human anatomical position is divided into planes. These are:
- Frontal (coronal)
- Transverse (axial)
Directional terms help physicians understand how different parts interact. These include:
Anterior – Facing the front of the body
Posterior – Facing the back of the body
Proximal – Close to an original reference
Distal – Far from an original reference
Superior – Toward the top a structure
Inferior – From the bottom of a structure
Superficial – Close to the body’s surface
Deep – away from the body’s surface
These are just a few terms you may encounter as a medical records specialist. There are many more that you will learn as you delve into an exploration of anatomy, physiology, and medical terminology.
Health Information Technician Diploma
After completing the 8-month diploma program at our El Cajon | San Diego Health Information Technician School, you have the option to continue in the Health Information Technician (HIT), Associate of Applied Science program. The associate degree can be completed in an additional 6 months and contains general education courses, along with advanced courses in billing and coding.
Contact us today to learn more about medical records technician career opportunities offered at ATA College.