Medical Records Assistant

Medical Records Assistant

The primary purpose of the Medical Records Assistant is providing support to the Medical Records Nurse, the organization, maintenance, and security of medical records in compliance with federal, state, and facility policies. This role ensures timely and accurate filing, retrieval, and documentation of patient health information.

Job Duties & Responsibilities:

· Maintain and organize active and discharged medical records in compliance with HIPAA regulations.

· File clinical documentation into patient charts promptly and accurately (paper and/or electronic health records).

· Ensure all required documentation is present, complete, and signed in accordance with facility policy and applicable regulations.

· Prepare records for audits, state surveys, and regulatory inspections.

· Track, log, and process medical record requests from external parties (e.g., hospitals, insurance companies, legal entities) with appropriate authorization.

· Assist in assembling new resident charts and archiving discharged resident charts according to retention policies.

· Monitor timely completion of physician signatures and charting requirements.

· Support scanning, indexing, and electronic filing of documents into EMR systems.

· Communicate with nursing and administrative staff to ensure accurate and updated documentation.

· Assist with maintaining logbooks, forms inventory, and other clerical tasks related to health information management.

· Ensure confidentiality of all resident information in compliance with HIPAA and facility policies.

· Provide general support to the Medical Records Nurse or Health Information Manager as needed.

· Receive and follow work schedule/instructions as outlined in facility policies and procedures.

· Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.

· Assist in organizing and maintaining the facility medical records system in compliance with corporate, state and federal regulations.

· Code and quantify records from admission to discharge.

· Maintain a documented, organized system which is readily accessible by other authorized professionals.

· Ensure that all reports are completed within established time frames.

· Schedule and maintain a time schedule for all interdisciplinary meetings and keep appropriate personnel informed of the schedule.

· Pull charts for physicians' rounds each week and insure that documentation is present.

· Monitor Restrain and Bowl and Bladder Programs to insure documentation is present.

· Review admission information for accuracy and completeness within 24 hours of admission.

· Ensure that discharge records and chart are completed within 72 hours of discharge and arrange the file in chronological order in each section so that material can be retrieved in an efficient manner.

· File lab and x-ray reports on charts daily.

· Review physician orders (including telephone orders) and monitor to be sure that lab, x-ray, diagnostic tests, consultations, etc., have been scheduled and followed through.

· Maintain log/roster to identify when care plan meetings are due.

Job Requirements:

Education

· LPN license preferred, CNA also considered

· Some business training preferred

· Medical Records certification preferred

Experience

· Must have two (2) years' experience in medical records.

· Must have a minimum of six (6) months of experience in a health care environment

· Must have a typing speed of 45 wpm or greater

· Must be familiar with Windows computer environment

· Must have general office and clerical skills

· Must have excellent communication and interpersonal skills

· Must possess a practical knowledge of medical terminology and record keeping

· Must be organized and detailed in work performance