Medical Records Specialist: The Person Behind Your Electronic Health Record (EHR)

Nowhere is record-keeping more critical and life-saving than in the medical arena.  As a result, the person entrusted with the accuracy and orderly maintenance of those records, the Medical Records Specialist, has tremendous responsibility placed on his/her shoulders.

In an increasingly digital world, Electronic Health Records (EHR) have acquired prominence at par with other vital digital records – including records about a person’s educational achievements, and financial and banking records. However, there is one critical distinction: If the Medical Records Specialist isn’t trained or qualified at doing the job, your life could very well be at stake!

What is an Electronic Health Record

Prior to today’s much broader vision of health-care delivery, physicians were narrowly practice-focused. That’s when they collected and compiled Electronic Medical Records (EMR), which was a slightly enhanced form of paper records related to a specific practice, albeit in a digitized medium. The introduction of the Electronic Health Records (EHR) system has broadened that focus.

Typically, an EHR is the documentation of any medical interaction a person might have with qualified medical practitioners. If it relates to your medical condition, a qualified Medical Record Specialist will ensure it gets into your digital file.

Today, most medical interactions are initiated, processed and terminated digitally. In their wake, they sometimes leave a digital trail that spans the gamut of digital data – some of it very structured, other not as concise or succinct. Not all of that data needs to be rolled up into final electronic health record-keeping.

It is the Medical Record Specialist who collects, codes, sorts and collates most of that data, and maintains it as a record of useful information (as opposed to raw data) that medical professionals rely upon to make informed health care decisions to treat patients.  However, there’s much more to EHRs than simply being a digitized version of paper-based records.

Electronic health record systems offer a much broader array of convenience than the paper-based recording and filing system provided. With the help of the Medical Record Specialist, once records are correctly coded, classified and captured into an E.H.R system, they can then be shared across the continuum of health-care providing institutions, including Pharmacies, Laboratories, Emergency Rooms, Senior-care facilities, Imaging Services, Mental Health-care institutions, Physician’s practices and Walk-in Clinics.

Your electronic health record is therefore a collection of information gathered from across all of these, and many other, health-care institutions and facilities.

What kind of information does an E.H.R. contain?

Whether it is a visit to your General Practitioner (GP) for a routine physical exam, a trip to a dentist for a Root Canal, or an unexpected rush to the ER – a stream of electronic data is generated at various stages of that visit. And as part of their job, the Medical Record Specialist will ensure that appropriate data is captured and recorded at various data-points in the cycle.

Some of the critical data elements that E.H.R Specialists collect, to create your Electronic Health Record, includes:

• Patient demographics
• Medical and medication histories
• Vital signs
• Patient progress notes
• Diagnosis
• Immunization details
• Lab tests and results

It is important to remember that a Medical Records Specialist doesn’t just collect descriptive information as part of the E.H.R compilation process. E.H.R Specialists also include charts and images, such as Radiology images, CT Scans, X-Rays and Mammographs, which are appropriately coded and classified as part of EHR.

It is also significant to understand that the E.H.R Specialists might include information in your E.H.R which may, at first, seem non-medical in nature; but that can help health care professionals provide a higher level of care. For instance, when a Medical Records Specialist documents race, ethnicity or foreign countries visited in the past 6 months, it might not seem clinically relevant, but it definitely could influence your medical professional’s decisions when prescribing a course of treatment.

What do E.H.R. Specialists do? 

As indicated earlier, EHRs are a natural outcome of any medical interaction, whether planned or emergency in nature, between patients and medical professionals. E.H.R Specialists are therefore found wherever medical services are provided, including:

• Hospitals
• Medical Offices
• Clinical facilities
• Group Practices
• Medical Insurance Offices

Amongst the array of responsibilities entrusted to the Medical Record Specialist are:

• Creation of patient records
• Collection of patient demographic data
• Collection of medical insurance information
• Coding and billing of patient services
• Auditing of patient records
• Processing release of information requests

In many cases, the Medical Records Specialist is not only responsible for initiating the collection of an item in your electronic health record, but they may also be responsible for validation, authentication and verification of ancillary data that is then captured as part of your E.H.R.

How do I become an E.H.R. Specialist?

The E.H.R Specialist is instrumental in ensuring the accuracy and efficacy of the electronic health record. Therefore, he/she must have suitable training and qualification to ensure those records are properly created and maintained.

You can become an E.H.R Specialist if you:

• Are inclined towards understanding how medical practices and administrative processes work. Ideally, you would have some exposure in an environment such as a doctors’ practice or other health-care practice
• Love learning about new software data entry systems used in capturing and creating electronic health care records
• Are willing to pursue a program of study, approved by the N.C. Community College System
• Pass the Certified Electronic Health Records Specialist (CEHRS) examination

Training curriculum, such as that of the College of Wilmington’s Electronic Health Records Specialist Program, aims to provide individuals with the necessary skills and training needed to manage electronic medical records. As a future Medical Records Specialist, you’ll also learn how to code and bill for patient services delivered across the continuum of the health care systems.

Through an intensive 730-hour program, such pre-requisite training includes:

• Medical Terminology
• Anatomy and Physiology
• Pharmacology
• Diagnostic and Procedural Coding
• Medical Office Insurance process and procedures
• Administrative Procedures

and many other related topics.

The College of Wilmington’s E.H.R Specialist program ensures that you are fully equipped, not only with the skills and knowledge necessary to create and manage EHRs, but also with the pre-requisite knowledge required to ensure that, as a Medical Records Specialist, you’ll be able to understand the significance of the records you are initiating and managing.