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. When assembling patients' health information, technicians first make sure the medical chart is complete. They ensure all forms are present and properly identified and signed, and 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 also on their knowledge of disease processes. The DRG determines the amount the hospital will be reimbursed if Medicare or other insurance programs using the DRG system cover the patient. 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. Health information technicians' duties vary with the size of the facility. In large to medium facilities, technicians may specialize in one aspect of health information, or supervise health information clerks and transcribers while a health information administrator manages the department.