Medical Records Technician (HIT)

Job Title

Medical Records Technician

Duties

Duties include but are not limited to: Preparing lists of paper health records needed for signature(s) that are located in the incomplete record area for distribution to appropriate service lines (i.e., Medicine, Surgery, Psychiatry, etc.) or that are not complete in the electronic health record. Monitors delinquent dictation list for follow up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records. Notifies appropriate physician and other personnel of the status of dictation. Monitors house-staff rotation schedule and contacts resident house-staff to ensure completion of records prior to departure from the Medical Center. Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects utilizing the Patient Treatment File (PTF) and PTF microfiche. Participates in approved quality improvement focused reviews. Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements, and to satisfy current Medical Center performance measures. Preforms analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient the report belongs to and filing/assigning it correctly. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Performs clerical or technical program support work for the Incomplete Records/Transcription Unit in support of the Health Information Management program of this facility. Performs program support functions for Health Information Management in the areas of Transcription and Incomplete Medical Records. Performs general program support work such as the collection, compilation, research, and/or tracking of data and program information. This includes, but is not limited to, determining which reports need to be dictated and/or signed by the clinician, identifying physicians with delinquent medical records, identifying which dictated reports have been returned and completed by the transcription vendor. Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system. Works independently resolving record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed. Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff. Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient the report belongs to and filing/assigning it correctly. Duties may also include the generation of various statistical reports to track these errors. Makes appropriate recommendations for changes or solutions and facilitate appropriate recommendations for corrective action when authorized so continued filing errors do not occur. The Medical Records Technician serves as technical expert in health record content and documentation requirements. Medical Records Technician is responsible for performing quantitative and qualitative reviews of health record documentation. Medical Records Technician is responsible for ensuring that all patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed. Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements. Other duties as assigned. Duties may slightly differ depending on grade level you are selected at.

Work Schedule: Monday-Friday 8:00am-4:30pm or as determined by supervisor. Functional Statement #: 09388-F. Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized.