This record includes information the patient provides about their symptoms and medical history, and also the results of examinations, reports of x rays and laboratory tests, and diagnoses and treatment plans. Medical record technicians organize and evaluate these records for completeness and accuracy. When assembling a patient's medical record, technicians, who may also be called health information technicians, first make sure that the medical chart is complete. They ensure that all forms are present and properly identified and signed, and that all necessary information is on a computer file. Sometimes, they talk to physicians or others to clarify diagnoses or get additional information.
Technicians assign a code to each diagnosis and procedure.
They consult a classification manual and rely, too, on their knowledge of disease processes. The DRG determines the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs that use the DRG system. Technicians also use computer programs to tabulate and analyze data to help improve patient care, to control costs, to be used in legal actions, or to respond to surveys. Tumor registrars compile and maintain records of patients who have cancer to provide information to physicians and for research studies. Medical record technicians' duties vary with the size of the facility.