Medical Record Administration

Written by Carolyn Larson
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Medical record administration is a position requiring a combination of training and experience in health care and business. Knowledge of the health care environment in general is necessary to understand the relationship of the department to the whole organization. Training in clinical information systems and reimbursement for health care facilities is imperative. The medical record department is vitally connected to each of these.

Many legal issues arise in medical record administration that must be handled properly. The necessity to maintain patient confidentiality is a priority based on the requirements of HIPAA. Malpractice, risk management, and other issues demand a thorough understanding of the medicolegal prerequisites for the use of records. It is the responsibility of the supervisor or administrator of the department to monitor compliance of the required standards. Non-compliance in any area can bring a huge fine to the institution.

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Proper financial reimbursement is determined by the appropriateness of the coding. Accurate coding requires in-depth training to interpret medical data and reports. It is essential to understand diagnosis codes and treatment procedure codes in order to determine the exact ones to file to the insurance company. An error in coding will affect the reimbursement from the insurance company. Some insurance companies will withhold payment completely until a full audit of the patient's charges has been completed. This can take weeks to resolve.

Medical record administration personnel have the task of overseeing all the activities of the department. They generally will interact with other top-level administrators in a healthcare setting sharing in the identifying, planning, and implementation of hospital-wide plans for overall improvement. Every department in the hospital is influenced in one way or another by medical records activities. Some supply information and services while others receive information and services. Either way, it requires good communication skills and expert knowledge to fill the position adequately.

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