Non-Clinical - Health and Information Management - Medical Records Clerk

Health Info Clerk

The HIM Clerk processes Health Information under the direction of the HIM Director or designated supervisor. This processing includes but is not limited to: collecting and/or delivering health information/hard copy medical records for patient care and processing the surgical list; retrieval of medical records, pick up of discharged patient records from nursing units, locating and following up on missing medical records, prepping, scanning and filing of medical records and loose reports, preparation of documents for storage via scanning or boxing, answering telephones; and/or assisting physicians and ancillary staff with health information requests. As time permits, may assists with preparation of medical records for destruction.

Specific skills needed:

• Demonstrates knowledge of medical records and medical record documents.
• Ability to process work using both alphabetical and numerical filing systems.
• Must be well organized and demonstrates an aptitude for accuracy and attention to detail.
• Demonstrates effective communication, interpersonal skills, and ability to follow instructions.
• Ability to be courteous, tactful, and cooperative throughout the day.
• Ability to concentrate and maintain accuracy despite frequent interruptions.
• Legible writing and printing is mandatory.
• Basic computer skills and keyboarding skills; typing speed of 30 wpm.

Education/experience/training:

• Required: Knowledge of Windows Software
• Preferred: Familiarity with electronic medical record systems, knowledge of medical terminology, previous HIM Department or medical office experience, valid California driver's license, motor vehicle, motor vehicle insurance and current registration, high school graduate or GED

Duties and responsibilities:

1. Safeguards and preserves the confidentiality of patient's protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital, and departmental policies.
2. Ensures a safe patient environment and adherence to safety practices per policy.
3. With consideration to age, employee utilizes the approved process to resolve biophysical, psychological, educational, and environmental needs of patient/significant other when administering care.
4. Logs out charts that are requested so that location can be tracked.
5. Answers the telephone and directs calls to appropriate area of the department.
6. Retrieves daily discharge patient records and old records from nursing units, ambulatory surgery center and the emergency department; follows up on all missing records. Processes all current discharged inpatient or outpatient records and previous records according to established policies and procedures. Ensures correct face sheets are on the front of the medical record.
7. Checks each original document and preps medical records and documents for scanning. Verifies all documents belonging to the record are being prepped (i.e., check name, medical record number and account number). Prints cover sheets and mounting sheets as required. Identifies documents with poor quality stamp if document is hard to read. Prepares, scans and quality checks reports.
8. Ensures scanning equipment is properly cleaned and maintained per department policy.
9. Assists with ongoing projects with others as requested.
10. Adheres to daily production standards per department policy.
11. Understand hospital and department operations, policies and procedures and can apply them to any situation.
12. Demonstrates a consistent level of performance; strives to maintain a steady level of productivity and provides consistent effort.
13. Must be able to communicate effectively with all ages of customers served.
14. Abides by and strongly enforces all compliance requirements and policies and performs his/her responsibilities in an ethical manner consistent with the organization values.
15. Performs other related duties as needed/assigned or directed.

Personal qualities:

• Communicates effectively and express ideas clearly.
• Actively listens and always follows appropriate channels of communication.
• Detail oriented.
• Punctual.
• Ability to establish priorities.
• Organized and dependable with a positive appearance and attitude.
• Always strives to make good use of time, seeks out work that needs to be completed.
• Reports free time to supervisor.
• Ability to work in a high activity area.
• Maintains a safe, neat, and orderly workstation.