Ld Medical Records Abstractor

Medical Records Abstractor

Dr. Alison Hipwell co-directs the Pittsburgh Girls Study (PGS) in which a sample of 2,450 girls from the City of Pittsburgh has been followed annually for 20 years to track developmental patterns and contextual influences on health. Several current projects are focused on stress exposures and perinatal, metabolic, and cardiovascular health. This role will support the Pittsburgh site of the NIH ECHO (Environmental Influences on Child Health Outcomes) Study, a large-scale, longitudinal study of pregnant women and their offspring.

The Ld Medical Records Abstractor will work alongside the Research Manager to request research participant health records from hospitals outside the UPMC system and abstract data from internal and external health records according to the established study protocols. This role will coordinate all aspects of the abstraction process, including development of training, research participant tracking, and quality control measures.

This position is grant funded.

Responsibilities:

• Demonstrate a service-oriented approach to position by conveying courtesy, respect, enthusiasm and a positive attitude in work situations, by showing initiative and offering assistance to other staff members and office personnel in the completion of the department's work, and make patient care and/or departmental service the first priority.
• Assist in the development of abstracting policies, procedures, system demonstrations and training materials.
• Interact directly with physicians and office staff to track these missing records and resolve data abstracting/data entry issues.
• Request health records from systems outside UPMC and perform a thorough review of the documentation within the outpatient medical record (eRecord and paper records) to enable accurate and active medication assignment and patient information into the study database (REDCap) by understanding disease processes and clinical interpretation of medications administered during outpatient visits and labor & delivery.
• Prepare weekly abstracting productivity statistics and present this information to the Research Manager on a weekly basis. Request records and complete abstraction within predefined timeframes.
• Actively train and assist clinic/physician office staff and other abstractors in regards to abstracting the essential patient medical data set into the study database (REDCap)
• Assist in training in orientation of new abstractors and provides appropriate feedback.
• Assist manager with performing quality assurance studies.
• Review completed abstracts on a daily basis for overall accuracy and reports any problems to the Research Manager.
• Work directly with abstractors to answer questions to assist them in their abstracting efforts ensuring data integrity in the study database (REDCap).
• Attend eRecord training classes and study-specific trainings as assigned by management.
• Coordinate missing chart report for abstracting purposes for follow up to obtain records that were initially unavailable.
• Interact with the national ECHO consortium study staff to resolve data queries related to medical record abstraction and obtain protocol clarifications as needed.

• Knowledge of medical record format and content of patient records.
• 3 years of experience.
• Ability to review records read physician documentation and verifies patient identification.
• Strong command of medical terminology and understanding of medical abbreviations, diagnosis information and prescription drugs.
• Strong computer skills.
• Detail oriented and possess a high degree of concentration to assure accurate data abstraction.
• Ability to perform job responsibilities and make decisions without daily direct supervision.
• Ability to research prescription drugs commonly found in patient charts.
• Knowledge of terminal digit numbering and filing systems.
• Ability to identify medical record forms, standard and nonstandard, and their appropriateness for inclusion in the eRecord.
• Ability to travel within a 2 to 3 hour drive of Pittsburgh and work flexible hours (i.e. some evening and weekend hours may be necessary periodically).
• Maintain strict confidentiality of patient information and adhere to HIPAA regulations.
• Ability to perform timely, high volume, tedious data review and entry into the application.
• Interact tactfully and professionally with clinic/physician/project staff and management.
• Excellent organizational skills, written/verbal communication skills, interpersonal skills, conflict resolution skills and problem solving skills.
• Capable of managing multiple demands and working a flexible schedule as the job demands.

Licensure, Certifications, and Clearances: RHIA, RHIT, RN or LPN preferred.

• Act 31 Child Abuse Reporting with renewal
• Act 33 with renewal
• Act 34
• Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran