Medical Records Technician: Education Requirements, Job Duties & Skills

The Basics

When you think of a career in healthcare, you may consider jobs on the frontlines, such as a nurse or physician assistant. But there are also plenty of healthcare jobs behind the scenes, such as a medical records technician.

Whether you are a patient in the hospital or have a regular checkup with your doctor, the encounter is documented by your provider. The forms and papers you sign when you are admitted to the hospital are also filed into your medical chart.

All the information from every medical appointment, test and procedure is compiled and becomes part of your medical record. Accurate medical records are needed to provide good patient care and to protect both the patient and medical provider rights. That’s where the job of a medical records technician comes in.

What is a Medical Records Technician?

A medical records technician is a healthcare professional who is responsible for maintaining, organizing, and reviewing patient’s health records. Medical records technicians are also sometimes called health information technicians.

Information included in a medical record may include medical histories, diagnostic test results, and treatment plans. All records and forms are identified, signed, and maintained in the correct location in a patient’s medical record.

Technicians ensure that the information is organized accurately and includes the required information to be compliant with laws, hospital policies, and insurance company’s regulations. Medical records technicians may be required to maintain records in paper files or electronic record systems.

The work technicians provide is vital for a few reasons. The healthcare industry has become increasingly complex. For example, insurance companies require specific factors to be documented for reimbursement. If certain things are not included in a medical record, then a bill cannot be processed, and the provider cannot get reimbursed.

Information in a medical record also needs to be classified accurately for various registries and databases. Federal laws also require patient’s medical records are secure, and privacy requirements are met. Medical record techs must adhere to specific laws along with the policies of their organization.

An accurate medical record is also crucial for good patient care. If the medical record is missing something, it prevents providers from getting a clear and complete picture of the patient’s medical history, problems, and needs.

What is a Certified Medical Records Technician?

A certified medical records technician has met the minimum requirements to obtain a credential in the field of information technology. Although certification is not required for employment, an increasing number of employers prefer to hire a medical records technician that has earned a certification.

The most common certification offered is through the American Health Information Management Association (AHIMA). Through the AHIMA, applicants can earn a registered health information technician credential. Requirements for earning the credential include completion of an associate degree program in health information management or closely related degree. Applicants for the credential must also pass a written exam. The AHIMA also offers a credential as a certified tumor registrar for medical records technicians that work in oncology units or oncology practices.

Other organizations, such as the Board of Medical Specialty Coding and Compliance, also offer certifications that could be beneficial for medical records technicians.

Being a certified medical records technician can improve earning potential and may help give an applicant the advantage when applying for a job. Certified medical records technicians also may be more likely to move into supervisory positions.

What Does a Medical Records Technician Do?

The responsibility of a medical records technician is to manage patient’s health records. But a lot of details go into organizing and maintaining records. Keep in mind; specific duties may vary depending on the place of employment. Typical responsibilities may include transferring information from physician notes into a patient’s medical record. For example, techs may enter data including patient demographics, the extent of the patient’s disease, and diagnostic procedures completed. Transferring information may involve transcribing notes from audio recordings into a computer charting program.

Medical record technicians also may audit or review health records to ensure accuracy and compliance with federal laws and insurance regulations. Technicians may notify providers about deficiencies in the medical record.

Technicians often assign specific codes or categories to patients for insurance purposes and statistical analysis. Categorizing patients is usually performed through various types of computer software programs. Depending on the size of the facility or office, medical records technicians may take on certain responsibilities, such as processing patient admission and discharge documents.

It is also often the job of the medical records technician to access or gather medical records for doctors, agencies, and other medical personnel as needed. Techs must adhere to laws regarding how information is released. For example, consent forms may have to be signed by patients before information can be released to other providers.

Where Does a Medical Technician Work?

Medical records technicians work in a variety of healthcare settings. According to the United States Bureau of Labor Statistics, in 2016, medical records and health information techs held just over 206,000 jobs. The most common place of employment for medical records techs is hospitals.

Although hospitals employed over 35 percent of medical records technicians, they also work in other settings where health information and medical records are used. For example, technicians work for insurance companies, physician practices, and pharmaceutical companies. Some medical records technicians are also employed by nursing homes, home health agencies, and rehabilitation centers. A small number of medical records techs may find jobs in government agencies and software vendors.

Medical records technicians typically work in an office and may have to spend many hours at a computer. Although many medical records techs work during daytime hours, some techs may be required to work evenings. Weekend and holiday work may also be required in healthcare facilities that are open all the time, such as acute care hospitals and medical centers.

What are the Requirements to Become a Medical Records Technician?

Educational

There are currently no formal educational requirements to become a medical records technician. Medical records technicians are not licensed and are not required to have a specific degree. Although on the job training is possible, most employers prefer to hire someone that has completed some training as a medical records technician.

For entry level into the field, a certificate program may be enough. Certificate programs typically take anywhere from six months to a year to complete. The average number of credits or units required is about 24. The goal of the program is to provide students with the needed education and training to enter the workforce quickly.

Typical courses in a medical records certificate program include medical terminology, anatomy, and introduction to medical records.

Admission requirements for a certificate in medical records technology are usually a high school diploma or a GED. Certificate programs are typically offered through adult education programs, private schools, and online.

The next level of training for a medical record technician is an associate degree program. Associate degree programs in medical records technology or health information technology usually take about two years of full-time study to complete. Typically, 60 units need to be completed. The goal of an associate degree program in medical records technology is to prepare a student to work in information technology and also qualify for the medical records certification exam if desired.

To earn an associate degree in information technology or medical records technology students take classes, such as electronic spreadsheets, legal issues in healthcare systems, and health statistics.

Associate degree programs in medical records technology are offered at private technical schools and community colleges. There are usually not extensive admission requirements, but a high school diploma or GED is required to be admitted to an associate degree program in information technology.

There are not bachelor degree programs specifically for medical records technology. Bachelor and graduate degree programs are available in health informatics, which is different than health information technology.

Licensure/Certification

Medical records techs are not required to become certified. But earning a certification can increase employment opportunities and earning potential.

To earn a certification from the American Health Information Management Association, applicants need to show proof of completion of an associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education. Applicants must also pass a multiple-choice exam covering topics, such as data, structure of medical records, and privacy laws.

What is an Online Medical Records Technician Degree Program?

An online medical records technician program prepares students to work as information techs using medical records software. These programs usually award either a certificate or an associate degree after completion of the required classes.

Classes in an online medical records technician program are the same type that are offered in a traditional classroom. Since a practical or internship is usually not required for a certificate or associate degree in medical records technology, the entire program can be completed online.

All of the classes are offered online, and many of the programs are self-paced, which means you can complete a class in the timeframe that works for you. The online program is convenient and allows medical records techs to enter the workforce quickly. For example, some online medical records certificate programs may be completed in three to six months.

What Does It Take to Become a Medical Records Technician?

Working as a medical records technician does not require direct patient care. But techs still play a vital role in helping patients. But how do you know if the job is right for you? Ask yourself if you have the skills, qualities, and personality traits listed below, which can help you succeed in the profession.

Are you detail oriented? Medical records contain a lot of details. The details matter, and if mistakes are made, it can change the way a person is treated or a provider is reimbursed. Medical records technicians should be thorough and pay attention to details.
Do you have good technical skills? Many healthcare facilities are using electronic medical records. Techs need to have good computer skills and be comfortable learning new software programs. Medical records technicians often use various medical programs including classification software and document management software.
Are you ethical? Medical records are private, and patients have a legal right to have their privacy protected. Medical records technicians have access to patient’s personal information including financial and insurance information along with health records. Technicians should have a thorough understanding of how to ethically handle information.
Do you have strong communication skills? Medical records technicians have to interact with doctors and other medical professionals. They may also have to talk with patients and their family members, which makes strong communication skills a must.
Can you multitask well? There are times medical records technicians are pulled in different directions. For example, techs may have to deal with requests to access information, entering data and handling calls from insurance companies all at once. Technicians need to know how to prioritize appropriately.

What are the Advantages and Disadvantages of Being a Medical Records Technician?

As with any career, there are pros and cons to the job. While there are several advantages to working as a medical records technician, there are also a few disadvantages. It’s also important to understand everyone is different. What one person views as a disadvantage, someone else may see as an advantage. Below are some general advantages and disadvantages of working as a medical records technician.

Advantages

Working as a medical records tech provides opportunities to work in various settings: Medical records techs who want a change of pace from a hospital can work in home care, a doctor’s offices, and insurance companies. The ability to change settings may keep the job fresh.
Medical records tech work in healthcare without direct patient care. Bedside care is not for everyone. For those who want to work in the medical field and help people, but don’t want the blood and gore, working in medical records may be a good fit.
There are different opportunities for specialization: Medical records technicians can specialize. For example, techs can become a release of information specialist or a medical records supervisor.
The field of medical records and information technology is growing: As electronic medical records continue to be implemented in more healthcare facilities, the need for medical record techs is going to grow.
You can start a career as a medical records tech quickly: The minimum training to work as a medical records technician can be completed in less than a year. For those who want to work in healthcare and get into the workforce quickly, becoming a medical records technician is a good option.

Disadvantages

Many hours are spent in front of a computer: Much of the work done by a medical records tech involves using computer software to compile and organize patient’s health records.
Jobs may require weekends and holidays: Medical records techs that work in healthcare facilities that are open 24 hours may have to work weekends, evenings, and holidays.
Frequent updates to software may require relearning certain aspects of the job: Medical software continues to change and be updated, which means you may always be learning something new.
Mistakes can be costly, which makes the work stressful at times: Medical records are reviewed during lawsuits, financial disputes, and employee issues. A lot rides on the accuracy of medical records, which can make the job stressful.

How Much Does a Medical Records Technician Make?

According to the United States Bureau of Labor Statistics, in 2016 the annual salary for medical records technicians was just over $38,000 a year. Experience plays a role in earnings, But the setting in which a medical records tech works also determines salary.

Medical records technicians who work in hospitals tend to earn about $41,000 a year, which is a little more than average. On the lower end are medical records techs who work in doctor’s offices and earn about $33,000 a year.

The geographic area also plays a big part in how much you can expect to earn as a medical record technician. Top paying states are spread out all over the country. For example, according to the BLS, New Jersey pays medical records techs the highest salaries in the country with Alaska coming in second.

What is the Job Outlook for Medical Records Technicians?

The outlook for medical records technicians is good. According to the United States Bureau of Labor Statistics, the need for medical records technicians is expected to grow by about 14 percent through the year 2026.

An aging population will likely result in an increased need for medical care, which creates a demand for medical records techs. Laws and insurance regulation also continue to evolve, which means there is a continued need for qualified professionals to ensure medical records are in compliance. There is also an increase in the number of healthcare facilities that are transitioning to electronic medical records, which has led to an increased need for qualified medical records technicians.

In addition to hospitals, opportunities are expected to grow in large group doctor’s practices, residential care facilities, and outpatient care centers. Medical records technicians who have certification will likely have the most opportunities.

What Professions are Similar to Medical Records Technician?

Below are a few careers that are similar to medical records technicians.

Health Information Technologists: People who work in health information technology design and develop informational systems, such as medical charting software for the healthcare industry. A bachelor’s degree is often required.
Medical Assisting: Medical assistants are involved in ensuring a medical practice runs efficiently. They may assist doctors with minor office procedures, prep patients for appointments, and perform office tasks, such as scheduling appointments and billing. Medical assistant programs take between one to two years to complete.
Medical Billing and Coding: Medical coders and billers assign each diagnosis and procedure a specific code, which is used for billing and insurance companies. Billing and coding programs can be completed in one to two years.

Medical Records Technician Career Guide