This record includes information the patient provides concerning their symptoms and medical history, the results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans. Health information technicians organize and evaluate these records for completeness and accuracy. Health information technicians, who may also be called medical record technicians, begin to assemble patients' health information by first making sure their initial medical charts are complete. They ensure all forms are completed and properly identified and signed, and all necessary information is in the computer. 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 classification manuals and rely, also, 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 using the DRG system. In addition to the DRG system, coders use other coding systems, such as those geared towards ambulatory settings. Technicians also use computer programs to tabulate and analyze data to help improve patient care or control costs, for use in legal actions, or in response to surveys. Tumor registrars compile and maintain records of patients who have cancer to provide information to physicians and for research studies.