WARD CLERK (Intrem)

• Assist in organizing, planning & directing the medical records section in accordance with established policies and procedures. • Maintain a working rapport with other departments in the facility to assure that medical records can be properly maintained. • Assist in recording all incidents/accidents. File in accordance with established policies and procedures. • Collect, assemble, check, and file resident charts and personnel records as required. • Ensure incomplete records/charts are returned to nursing service for correction. • Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing. • Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures. • Maintain records of information taken from charts/records, i.e., type information, name of recipient, date, department, etc. • Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. • Maintain various registries as directed including register for admission and discharge of residents. • Collect charts, assemble them in proper order, and inspect them for completion. • Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.

• Assist in admission, transfer and discharge procedures as necessary.
• Answer telephone inquiries concerning medical records functions. Prepare

written correspondence as necessary. • Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies, etc.) • Assure that medical records taken from the department are signed out and signed in upon return to the department.

• File active and inactive records in accordance with established policies.
• Index medical records as directed.
• Other duties and responsibilities that may become necessary or appropriate to

meet the administrative needs of this facility.