People tell doctors all about their aches and pains, so that they can get treatment and relief from the pain. But in order to make the correct diagnosis and prescribe the best treatment, doctors need accurate and detailed health records that describe their patients’ medical histories. That’s where health records professionals come into the picture.
Health records professionals make sure that adequate records are taken for each patient, and that the records are organized, stored, and available for the patient's next visit. This may include information taken during previous visits, test results, and notes on any allergies the patients may have. Sometimes, they may also have to collect medical information for use in budgets, health care research, and even court cases.
When a patient visits a medical clinic or hospital, the health records professional retrieves that person’s file, and gives it to the doctor. Before treating a current illness, the doctor always reviews the file. This review is important. If the patient is allergic to certain medications or has a disease such as diabetes, special precautions may have to be taken.
Once the doctor has talked to the patient, any new treatment is recorded by entering a special code in the patient's file. When the patient leaves, a health records professional—who is familiar with all the codes—checks the file to make sure the information is complete. The file is then returned to the archives so that it is readily accessible and available for the patient’s next visit. This process happens every time a doctor or other health care professional meets with a patient.
Health records professionals must make sure that patient files are kept confidential. They must be aware of the various laws dealing with the disclosure of medical information. Generally, medical records can only be read by medical professionals, the patient, or anyone the patient authorizes, such as an insurance company.
These professionals may use some of the information they process to create reports about diseases and treatments. For example, they may calculate the number of cancer patients who have received and benefited from chemotherapy. Or, they may collect and present information that is used to develop budgets and control costs.
The term “health records professional” is often used to describe both health records technicians, who perform the duties mentioned above, and health records administrators, who supervise the technicians.
NOC Code: 1413