I. Responsibilities
A. Release of Medical Legal Information
1. Exhibits a working knowledge of Federal and State Regulations.
2. Develops, monitors and maintains policies, procedures and fee scales.
3. Responsible for follow through of all hospital litigation cases and assuring that the files remain in a secured area until the case is closed.
4. Assures that continuing education is presented to the staff of HIS regarding release of information.
B. Chart Completion by Medical Staff
1. Monitors the timely notification to physicians of deficient charts.
2. Develops, monitors and maintains policies and procedures relating to chart completion in accordance with JCAHO and Title 22 regulations.
3. Directly responsible for the suspension of medical staff privileges for incomplete records.
4. Reports infractions of medical staff bylaws, rules and regulations to the director.
5. Responsible for assuring that the Med Rec system is updated as enhancements are received and backed up as needed.
6. Directly responsible for reporting deficiency chart status to the Director.
C. Computer Systems
1. Knowledge of all computer systems used in the HIS department.
2. Trains and educates department staff on the correct use and functions of the computer systems as needed.
3. Works with the MIS department and the admitting department to resolve problems as they occur.
D. Daily Operations
1. Assures that the assembly, analysis process of discharged patient medical records is completed within specified time frame.
2. Assures that all documentation for each patient’s visit is placed within the medical records and it is in the correct chart.
3. Submits daily and monthly statistics to finance and administration.
4. Assures adequate staffing for all shifts.
Transcription:
1. Serves as a liaison between the hospital and outside transcription service.
2. Directs the flow of transcribed reports and monitors quality of work, quantity of work and physician dictation problems as needed.
3. Develops, monitors and maintains policies and procedures relating to transcription for both the hospital and physicians.
Permanent Storage of Records:
1. Assures there is adequate space for medical records to be stored in a safe and secure area.
2. Responsible for planning and presentation of need for additional storage space or alternative plans for storage of medical records.
Timesheets:
1. Responsible for timely and accurate editing timesheets for the Kronos time and attendance system.
E. Misc. Job Duties
1. Misc. job duties as assigned by Director.
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