Medical Records

PURPOSE OF YOUR JOB POSITION:

The primary purpose of your job position is to maintain medical records in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained.

DELEGATION OF AUTHORITY

As Medical Records, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

ESSENTIAL JOB FUNCTIONS STATEMENT:

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

SAFETY FACTORS:

Risk Potential to Blood/Body Fluids:

Category I: Tasks in this category involve exposure to blood, body fluids, or tissues, and require the use of personal protective equipment.

Category II: Tasks in this category involve no exposure to blood, body fluids, and/or tissues, but employment may require performing unplanned category I tasks.

Category III: these tasks require no exposure to blood, body fluids, and/or tissues, and category I tasks are not a condition of employment.

ESSENTIAL JOB FUNCTIONS & RESPONSIBILITIES

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 section in accordance with established policies and procedures.
• Assist the Medical Records Consultant as required.
• Maintain minutes of meetings/files 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.
• Collect, assemble, check and file resident charts and personnel records as required.
• Ensure incomplete records/charts are returned to nursing service for correction.
• Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
• Follow established policies and procedures for the medical records section.
• Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
• Maintain a record of authorized information taken 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.
• Index medical records as directed by the medical records consultant.
• Maintain various registries as directed including register for admission and discharge of residents.
• Type reports for physicians as necessary.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
• Assist in admission, transfer and discharge procedures as necessary.
• 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.
• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Clerk.
• Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.

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.

Staff Development

• Attend and participate in in-service educational classes and on-the-job training programs including annual OSHA and CDC in-service training programs concerning hazard communication, TB management, and blood borne pathogens.
• 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 work day, etc.

Resident Rights

• Maintain confidentiality of all pertinent resident care information to assure resident rights are protected in accordance with HIPAA regulations for health information.
• Knock before entering a resident's room.
• Assure that residents' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are followed.

Working Conditions

• 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 day, 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.

Educational Requirements

• Must possess, as a minimum, a high school diploma.

Experience

• On-the-job training provided in medical record procedures.

Specific Requirements

• Must be able to read, write, speak, and understand the English language.
• 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 be knowledgeable of medical terminology.
• 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.
• Be knowledgeable in micro-computers, data input and output.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements

(With or Without the Aid of Mechanical Devices)

• Must be able to move intermittently throughout the work day.
• 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 twenty-five pounds.
• May be necessary to assist in the evacuation of residents during emergency situations.