About Medical Record Keeping

Medical record, or health information, careers involve ensuring the accuracy and completeness of patient health information. The phrase "medical record keeping" is outdated terminology; this type of work is now referred to as "health information management." HIM responsibilities are mainly overseen by specially educated and credentialed medical professionals, called health information managers, administrators or health information technicians.

Job Responsibilities

• Medical record keeping involves overseeing patient health information in both paper and electronic formats. Health information managers and technicians ensure complete paperwork and documentation exist within a patient's medical record and that forms and reports receive appropriate authentication. Additionally, health information professionals guarantee the availability of patient information to physicians and other clinicians for ongoing patient care, as well as oversee the release of information to patients and approved organizations.

Environments

• Medical record keeping occurs in any organization housing health information, including hospitals, physician offices, outpatient clinics and governmental agencies. Most health information departments provide staff during regular business hours. However, large teaching hospitals and other facilities may rotate 24-hour staff to provide patient medical information as soon as needed.

HIPAA

• In 1996, the Health Insurance Portability and Accountability Act became law. HIPAA presented additional work in medical record keeping, because a portion of the law covers the privacy and security of both paper and electronic health information. Under HIPAA, health information professionals help to ensure that patient information is stored appropriately, protected from intrusion and released only as authorized.

Technology

• With advancements in technology, more health care organizations and physician offices use electronic medical records. EMRs redefined medical record keeping and the way that health information is stored, handled and retrieved. Health information professionals now need to possess a thorough understanding of computers, various software systems, data retrieval and analysis and reporting. Because information is now retrieved more quickly and accessed by a wider variety of people, EMRs present additional privacy and security concerns.

Educational Requirements

• Managers and supervisors overseeing health information management departments usually complete an associate degree in health information technology or bachelor degree in health information management. These programs teach how to retain records and maintain the privacy and security of patient health information. Some HIT graduates receive the Registered Health Information Technician credential after graduation. HIM program graduates become eligible for the Registered Health Information Administrator credential. Both the RHIT and RHIA are voluntary credentials that health information professionals may choose to complete as a sign of ethical and professional commitment to the industry.