Step-by-Step Guide to Medical Records Management

Learn about the process and requirements involved in medical records management.

Medical laboratory technicians play a key role in healthcare. They collect, manage and test patient specimens.  Patients’ test results are then deemed either normal or abnormal, and the results are entered into the patient record via a laboratory information system (LIS). Doctors rely on this data to help form a treatment plan for their patients.

(Click here to review our complete list of medical lab tech duties & responsibilities)

While lab results represent only part of a patient’s data, they must be managed under the same HIPAA (Health Insurance Portability and Accountability Act) guidelines as any other medical data. Whenever patient data is stored, HIPAA guidelines apply.

Below we will go over the details and procedures of medical record management.

You can learn more about the career path if you’re interested in becoming a medical laboratory technician.

What Is the Definition of a Medical Record?

A medical record is a report that contains all the health information of a patient. Doctors, nurses, and other healthcare providers use these records to understand the patient’s health history and to help diagnose patients and decide on possible treatment options.

What Information Makes Up a Medical Record?

A patient’s medical record comprises different areas or types of data. You’ll find the patient’s demographics, medical history, notes on the progress of conditions or overall health, diagnoses, medications, and allergies.

The data created by a medical laboratory technician makes up a large part of the patient’s medical record. Sample testing results become a part of the patient’s history moving forward and provide the foundation under the doctor’s diagnosis and treatment plan.

What Are Some Common Lab Tests in a Medical Record?

Laboratory testing results make up the core of a patient’s medical record. Medical laboratory technicians perform a variety of different tests using different pieces of laboratory equipment.

Here are five common lab tests performed by a medical laboratory technician:

• Complete blood count (CBC) — A complete blood count is a group of tests whose goal is to look at the types and numbers of cells in the patient’s blood. These include red and white blood cells, along with blood platelets. A complete blood count details the patient’s general health status, and it screens for disorders or nutritional problems. Conditions such as anemia, leukemia, and infection will typically be present in a blood count. As for diagnosis, blood counts help doctors evaluate symptoms such as fatigue, weakness, excessive bruising, and others health issues.
• Basic or comprehensive metabolic panel — Metabolic panels check the patient’s levels for various substances such as sodium, potassium, glucose, calcium, carbon dioxide, chloride, blood urea, nitrogen, and creatinine. These panels help with diagnosis and screening for certain conditions. They also show the efficacy of medications.
• Lipid panel — Lipid panels evaluate a patient’s cardiac risk, assessing total cholesterol, triglycerides, HDL, and LDL levels.
• Urinalysis — What’s found in the urine can indicate early signs of infection. Urinalysis can be used to monitor kidney disease, diabetes, and other diseases.
• Liver panel — Liver panels evaluate the quality of liver function and measure enzyme levels.

Does the Medical Laboratory Technician Deliver these Results to the Doctor?

The medical laboratory technician performs the most routine testing on a patient’s specimen. More complex testing is performed either by a Medical Laboratory Scientist or a Pathologist.

In most cases, the providers are able to get the results from the Laboratory Information System (LIS). Therefore, no direct reporting is needed by the Medical Laboratory Technician (MLT).  However, notification of critical values is given to the provider by either the Medical Laboratory Technician (MLT) or Medical Laboratory Scientist (MLS) and documented in the electronic chart.  In small rural facilities and surgical areas, test values may be given to the provider directly by the MLT or MLS, but this isn’t the norm only in extenuating circumstances.

What Role Does a Medical Laboratory Technician Play in Medical Record Management?

When a medical laboratory technician completes the doctor’s requested tests, they enter the results into the laboratory information system (LIS). The results are then available electronically to the providers.  Any critical results will be notified to the provider and documented in the patient’s record.

Medical record management is included in the Clinical Laboratory Improvement Amendments (CLIA) within HIPAA compliance rules. These rules apply to both physical and computer data. For instance, if the medical laboratory technician (or anyone else involved with the patient’s care) makes a paper printout of a digital record, once its use has been fulfilled, the document must be shredded through a HIPAA-compliant shredder.

When a medical laboratory technician is viewing a patient’s record on a computer, such as when inputting new data, the technician must be careful when accessing or entering patient information. Patient information must be blocked from view when the computer is in an open space. This is to prevent others from seeing the patient’s confidential medical record.

It is rare for a patient to speak directly with a medical laboratory technician, but it can happen. If the technician receives a call from a person purporting to be the patient, the technician must have the caller verify their identity by asking for information such as birth date, address, or the last four digits of their social security number.

The job of medical laboratory technician is on our list of the best entry-level medical jobs in healthcare.

What Training is Required to Become a Medical Laboratory Technician?

Protecting patient medical records is essential to a medical laboratory technician’s job. Understanding the proper HIPAA protocols is part of the education involved when learning to become a medical laboratory technician.

To become a medical laboratory technician, a person needs to earn a Medical Laboratory Technician associate degree from an accredited institution. Brookline College offers an excellent program enabling students to earn their Medical Laboratory Technician degree in as few as 64 weeks.

Once you have your degree, you are qualified to become certified by one of two major credentialing organizations, ASCP Board of Certification or American Medical Technologists.

The final step is to acquire a license in the state where you want to work, although not all states require this.

Ready to Become a Medical Laboratory Technician?

The testing performed by medical laboratory technicians makes up a large part of a patient’s medical record, particularly when dealing with an acute illness or condition. Managing those records as required by HIPAA is an important secondary aspect of a medical laboratory technician’s job.

Of course, the main role of a medical laboratory technician is to test blood, urine, and other body fluid samples and to enter the patient’s test results into the laboratory information system (LIS). This is an important part of the diagnostic process and makes for a rewarding career. At Brookline College, we offer an accelerated medical lab technician program where you can earn the necessary Associate of Applied Science degree in as little as 64 weeks.

Beyond medical laboratory technician programs, Brookline College also offers training and degree programs for many other occupations in medicine and healthcare.