Medical Record Training
A medical records specialist is one who organizes all the documentation of a patient’s office visit. The documentation includes the record of the patient’s demographical information, the clinical history, the symptoms the patient presented with, the physical examination findings, the results of the imaging studies and laboratories done, the working diagnosis, and the treatment plan. Medical records specialists check these documents for accuracy and completeness, and they are responsible for filling out missing information. Documentation also includes other relevant files such as informed consents and billing details.
Due to the large number of patients that health care providers see each day, a medical records specialist should be efficient and organized. Because they are handling documents that are medical in nature, part of a medical record specialist’s training involves familiarizing with many aspects of medical practice. The medical record specialist must also have knowledge and experience in filing techniques, as vast amounts of papers go through his or her hands everyday, and he or she must file all of these for future use.
There are laws and guidelines for proper documentation, use, and maintenance of medical records. A medical record specialist must also be familiar with these as he or she is responsible for handling medical records.
In medical record training, it is important to acquire skills and knowledge on medical terminology. This includes knowledge on anatomy and physiology, diagnoses, and medical procedures. Specialists should also have knowledge on current health data requirements and standards, clinical coding systems and diagnosis classification, methods of reimbursing healthcare services from insurance companies, and management of database. Individuals can start even as early as high school, wherein they can take medically-related subjects such as biology and chemistry, and computer science courses. A medical record specialist must also be proficient in business English and must be familiar with medical billing and medical coding.
In order to be employed as a medical records specialist, one must have at least an Associate degree. Many community and career colleges offer a number of degree options and certificate training in medical records and related fields. The programs usually run for eight to twelve months. The requirements of each school vary, but usually, a high school diploma is required and having a typing speed of 65 words or more per minute is helpful. Programs include courses in English and computer software. There are also online classes offering training in medical records.
Most medical record training programs do not require previous medical experience. They usually begin with the basics, including background knowledge on medical terminology. The length of a training program usually varies. Some programs are self-paced, allowing faster and more dedicated learners to progress as fast as they like.
Once an individual completes medical records training, he or she can begin looking for employment with independent healthcare providers, hospitals, care facilities, or other medical-related companies.