Medical Records/Health Information Technician  What They Do

Just the Facts

Medical Records and Health Information Technicians Career Video

Compiles, processes, and maintains medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the heath care system. Processes, maintains, compiles, and reports patient information for health requirements and standards in a manner consistent with the healthcare industry’s numerical coding system.

This career is part of the Health Science cluster Health Informatics pathway.

A person in this career:

  • Protects the security of medical records to ensure that confidentiality is maintained.
  • Reviews records for completeness, accuracy, and compliance with regulations.
  • Retrieves patient medical records for physicians, technicians, or other medical personnel.
  • Assigns the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  • Processes patient admission or discharge documents.
  • Transcribes medical reports.
  • Resolves or clarifies codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.
  • Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Identifies, compiles, abstracts, and codes patient data, using standard classification systems.
  • Releases information to persons or agencies according to regulations.

Insider Info

Dig into the details and check out what people in this job have to say about their work.

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Working Conditions and Physical Demands

People who do this job report that:

  • You would often handle loads up to 10 lbs., sometimes up to 20 lbs. You might do a lot of walking or standing, or you might sit but use your arms and legs to control machines, equipment or tools.
  • Work in this occupation involves using your hands to hold, control, and feel objects more than one-third of the time
  • Work in this occupation requires being inside most of the time
  • Sound and noise levels are loud and distracting
  • Work in this occupation involves making repetitive motions more than one-third of the time
  • Work in this occupation involves sitting more than one-third of the time

Working in this career involves (physical activities):

  • Seeing clearly up close
  • Identifying and understanding the speech of another person

Work Hours and Travel

  • Overtime work

Specialty and Similar Careers

Careers that are more detailed or close to this career:

  • Coder --
  • Health Information Clerk --
  • Health Information Specialist --
  • Health Information Technician (Health Information Tech) --
  • Medical Records Analyst --
  • Medical Records Clerk -- Compiles, verifies, types, and files medical records of hospital or other health care facility.
  • Medical Records Coordinator --
  • Medical Records Director --
  • Medical Records Technician (Medical Records Tech) --
  • Registered Health Information Technician (RHIT) --