MODULE 1

HOW TO BECOME A MEDICAL RECORDS TECHNICIAN

Getting started:
 What do you know about medical records?
 Do you think it is a futuristic profession? Why?
 What is your first impression studying in medical
records?

Useful key words:

Diagnose – symptoms - prescribing medications – coding
– vocational

A medical records technician (MRT) occupies one of the few positions in healthcare requiring no
hands-on patient care, yet it is one of the most important jobs in the industry. Health care
providers rely on the information in a patient’s medical records in order to diagnose and treat the
patient successfully. The medical records technician plays a vital role in properly maintaining
these records of patient medical history.

Statement :
Yellow = verb
Green= Determiner
Red=Adjective
Blue=Preposition
Pink=Noun
Dark Blue=Adverb
Violet=Pronoun
Grey=Conjunction

Every day, people make tens of thousands of visits to doctors and hospitals across the country,
and each one of these visits involves a patient’s medical record. The doctor reviews a patient’s
history as described in the medical record prior to or during a patient's visit, and then conveys in
written or spoken notes the nature and content of the current visit. These notes detail symptoms,
possible diagnoses and follow-up actions, such as prescribing medications or further testing.

A medical records technician – now more commonly referred to as a health information

technician (HIT) – transfers the data from a doctor's notes into a patient’s permanent medical
record, and the accuracy and timeliness of this data is all-important to appropriate patient
treatment. A career as a medical records technician provides an excellent opportunity for detail-
oriented individuals who enjoy the privilege and responsibility of ensuring top quality care
without the patient contact that most healthcare positions require.
The focus is shifting from paper-based medical records to electronic health records (abbreviated
as EHR). Technological advances are creating more challenging practices around the areas of
access, privacy and security, quality, analytics, reimbursement and clinical documentation
improvement. Because of the significant growth in technological advancements with information
management, there are many opportunities and roles for an HIM professional.

For the medical records technician, the most common work environment is in a hospital setting.
These individuals usually work in roles that ensure the quality of the medical record is complete
and accurate. Where paper charts are still utilized, technicians may be involved in scanning and
indexing the paper documentation so that it can be displayed correctly in electronic form. When
there are discrepancies or deficiencies in the documentation, they will work with professional
staff such as physicians and clinicians to ensure the documentation is complete and accurate.

Another common role for the technician is often the specialization of coding diagnosis and
procedures based on the care a patient received so that the organization can be reimbursed for
those services. This is known as coding. Coding is used not only for reimbursement but also for
research and various registries for data reporting and trending.

In addition to hospital settings, MRTs are also employed in other areas where health information
is used, like insurance companies, software vendors, pharmaceutical companies, physician
practices, rehabilitation centers, home healthcare agencies, nursing homes, and government
agencies.

Aspiring medical records technicians should enroll in a two-year associate degree program,
making sure that the program is accredited by the Commission on Accreditation for Health
Informatics and Information Management (CAHIIM).
While still in high school, students with an interest in this career can prepare by taking classes in
health science subjects such as biology and human health, while also taking classes in computers,
math and business. Many vocational schools now offer programs to help young people explore
the growing field of health information management. There are also opportunities to take online
courses to assist the student with preparation for work in this field.

There are numerous junior college programs in medical records technology, though they
sometimes appear under slightly different names such as “health information technology.”
Again, make sure that the program is accredited by CAHIIM. The courses in these programs will
cover details of the most widely used medical coding systems; database management and
security; data analysis; and insurance industry practices.
MRTs may specialize in medical transcription, which is the transcribing of a doctor’s spoken
notes (dictation) into the computer. Another specialization is cancer registry, focused on
recording details of the many types of cancer that exist and their treatments. There is a national
cancer registry managed by the Centers for Disease Control (CDC), to which local registries
contribute their data. This and other specializations may be acquired either during schooling,
depending on the program, or on the job. There are many certification opportunities available
through the American Health Information Management Association, which provides additional
training resources – more details below!

Most employers prefer to hire registered or certified medical records technicians. The most
common certification is as a Registered Health Information Technician (RHIT), gained by
passing an examination administered by AHIMA. Being credentialed by AHIMA opens the door
for career advancement, thus improving salary earnings potential, enabling better networking
with peers in similar roles, and assisting with lifelong learning through continuing education.
Additional certifications can be obtained from AHIMA in order to increase individual
marketability. These include specialized certifications for coding (CCS/CCS-P), healthcare
privacy and security (CHPS), tumor registry (CTR), health data analysis (CHDA), and EHR
Credentialing (HIT Pro).

The best medical records technicians tend to have a natural attention to detail, gaining
satisfaction by seeing loose ends tied up in an organized way. Because health information is
confidential, MRTs are expected to have a high degree of ethical integrity, avoiding any
inappropriate sharing of details. The job nearly always involves following established guidelines,
typically under supervision, but there will be times when the technician must exercise his or her
own judgment to interpret certain notes and records. This will also involve careful
communication with medical and business staff.

Most medical settings are quite busy, and everyone working in this environment must be patient
and courteous while interacting with a wide variety of coworkers. The ability to stay focused in a
fast-paced environment while maintaining close attention to detail and an efficient workflow are
important qualities of the MRT.

To maintain the designation of RHIT, AHIMA requires 20 hours of continuing education every
2 years. As medical records technicians gain experience and additional training, there will be
opportunities for promotions and raises, especially in larger medical settings such as hospitals or
large practice groups. MRTs who show an inclination for lifelong learning, along with the
appropriate tact and decorum, will have the best opportunity to advance into supervisory
positions.

By Wendy James, RHIA, PMP

Retrieved from: http://www.innerbody.com/careers-in-health/how-to-become-a-
medical-records-technician.html

Task 1
1. Analyse the part of speech (such as, verb, adjective, adverb, etc) of each word from the text,
colour it, and do it in pairs.
2. Find the difficult words from the text, list them, and look up the dictionary.
3. Make a summary of each paragraph.
4. Answer :
2. Occupies = menempati
Requiring = menuntut
Rely = mempercayakan
Properly = dengan baik
Involves = melibatkan
Prescribing = meresepkan
Further = lebih lanjut
Conveys = menyampaikan
Commonly = biasanya
Referred = menunjuk
Opportunity = kesempatan
Advance = kemajuan
Environment = lingkungan
Utilized = menggunakan
 Reimbursement = penukaran pembayaran
Acquired =yang diperoleh

3. 1. Medical records is one of the important jobs in healthcare

2. The medical record noted all the patient details
3. Medical records now more commonly referred to as a health information technician
4. With advanced technology, medical records not only based on paper but also focus on
the electronic for documentation
5. A medical record technician work in roles that ensure the quality of the medical record
is complete and accurate
6. A medical record technician work with specializations of coding diagnosis
7. Information patient from medical record technician is used not only for the hospital
but also for other institution because it can give information
8. To become a medical record student in high school we can prepare by taking classes in
health science subjects
9. In addition to MRTs, there are specialization specific cancer, focused on recording
details of the cancer disease
10. There are employers prefer to hire registered or certified medical records technicians
11. The best medical records technicians tend to have a natural attention to detail,
gaining satisfaction by seeing loose ends tied up in an organized way
12. Something important from MRTs is the ability to stay focus on the work
13. As medical records technicians will gain experience and chance to raise

Task 2
Describing your profile: describe your own profile why you are now joining Medical
Records. You may make a simple essay, you may also make an oral description, you may
create a digital storytelling, you may illustrate it through a visual essay, or even you may
create a poem. Here are important points which can help you do this task.
 why you became a medical records student
 what you are doing now
 your career plans.