Medical records and health information specialists verify and validate patients' health information, including their medical history, symptoms, and examination and test results.
Medical records and health information specialists organize, manage, and code health information data. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.
Medical records and health information specialists typically do the following:
- Review patients’ records for timeliness, completeness, and accuracy
- Organize and update information in clinical databases or registries
- Use classification systems to assign clinical codes for insurance reimbursement and data analysis
- Electronically record data for collection, storage, analysis, retrieval, and reporting
- Maintain confidentiality of patients’ records
Medical records and health information specialists verify and validate patients’ health information, including their medical history, symptoms, examination and test results, treatments, and other information about healthcare services provided to patients. Their duties vary by employer and by the size of the facility in which they work.
Although medical records and health information specialists do not provide direct patient care, they work regularly with registered nurses and other healthcare workers. They meet with these workers to clarify diagnoses or to get additional information.
Medical records and health information specialists use electronic health records (EHRs) software, following EHR security and privacy practices to analyze electronic data and improve healthcare information.
The following are examples of types of medical records and health information specialists:
Cancer registrars review patients’ records and pathology reports to verify completeness and accuracy. They assign classification codes to represent the diagnosis and treatment of cancers and benign tumors. Cancer registrars conduct annual followups to track treatment, survival, and recovery. They compile and analyze cancer patient information for research purposes, and they maintain facility, regional, and national databases of cancer patients.
Health information technicians collect, analyze, and track treatment and followup information on patients. They respond to record requests and validate authorizations and other legal requests. These technicians also provide administrative support to other staff in the health information management department.
Medical coders assign the diagnosis and procedure codes for patient care, population health statistics, and billing purposes. For example, they might review patient information for preexisting conditions, such as diabetes, to ensure proper coding of patient data. They also work as the liaison between healthcare providers and billing offices.