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.
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.
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