Medical Records

General Purpose

The primary purpose of your job position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our facility's established privacy policies and procedures.

Essential Duties

Administrative Functions

• Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.

• Assist in organizing, planning and directing the medical records department in accordance with established policies and procedures.

• Assist the Medical Records/Health Information Consultant as required.

• Maintain minutes of meetings. File as necessary.

• 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 recording all incidents/accidents. File in accordance with established policies and procedures.

• Retrieve resident records (manually/electronically). Deliver as necessary.

• Files information such as nurses' notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.

• Collect, assemble, check and file resident charts as required.

• Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.

• Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.

• Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.

• Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized in our policies and procedures.

• Maintain a record of authorized information released 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. in accordance with current Privacy Rules.

• Index medical records as directed by the medical records/health information consultant.

• Maintain various registries as directed including register for admission and discharge of residents.

• Transcribe and type reports for physicians as necessary.

• Collect charts, assemble them in proper order, and inspect them for completion.

• Pick up and deliver resident medical records from wards, nurses' stations, and other designated areas as necessary.

• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.

• 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 and personnel, 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.

• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.

• Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.

• Report any known or suspected unauthorized attempt to access facility's information system.

• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this position.

Committee Functions

• Perform secretarial duties for committees of the facility as directed.

• Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.

Personnel Functions

• Report known or suspected incidents of fraud to the Administrator.

• Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.

Staff Development

• Attend and participate in mandatory facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.).

• Attend and participate in workshops, seminars, etc., as approved.

Safety and Sanitation

• Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.

Equipment and Supply Functions

• Report equipment malfunctions or breakdowns to your supervisor as soon as possible.

• Ensure supplies have been replenished in work areas as necessary.

• Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.

Budget and Planning Functions

• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

Other duties as assigned.

Supervisory Requirements

You are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Qualification

Education and/or Experience

Must possess, as a minimum, a high school diploma or GED. Must be able to type a minimum of 45 words per minute and use dictation equipment. A working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required. On-the-job training provided in medical record and health information system procedures. Must be knowledgeable of medical terminology. Be knowledgeable in computers, data retrieval, input and output functions, etc.

Language Skills

Must be able to read, write, speak, and understand the English language. Ability to read technical procedures.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability

Must possess the ability to make independent decisions when circumstances warrant such action. Must possess the ability to deal tactfully with personnel, residents, visitors and the general public. Must possess the ability to work harmoniously with other personnel. Must possess the ability to minimize waste of supplies, misuse of equipment, etc. Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices. Be able to follow written and oral instructions. Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical Demands

Must be able to move intermittently throughout the workday. Must be able to speak and write the English language in an understandable manner. Must be able to cope with the mental and emotional stress of the position. Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met. Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel. Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination. Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet. May be necessary to assist in the evacuation of residents during emergency situations.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Works in office areas as well as throughout the facility. Moves intermittently during working hours. Is subject to frequent interruptions. Works beyond normal working hours, weekends and holidays and on other shifts/positions as necessary. Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.). Attends and participates in continuing educational programs. Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants. Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses. Communicates with nursing personnel, and other department personnel. Is subject to hostile and emotionally upset residents, family members, personnel, visitors, etc. Is involved with residents, family members, personnel, visitors, government agencies and personnel, etc., under all conditions and circumstances. May be subject to the handling of and exposure to hazardous chemicals.

Additional Information

Note: Nothing in this job specification restricts management's right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons.

The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position.

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.