The primary purpose of the Medical Records Coordinator position is to assist the Charge Nurses in their day-to-day recording and charting of medical and/or administrative information.
JOB DUTIES & RESPONSIBILITIES:
- Receive and follow work schedule/instructions from your supervisor and as outlined in facility policies and procedures.
- Organize, plan and direct the medical records department in accordance with established policies and procedures.
- 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.
- Organize and maintain facility medical records system in compliance with corporate, state and federal regulations.
- Code and quantify records from admission to discharge.
- Maintain a documented, organized system which is readily accessible by other authorized professionals.
- Insure that all report are completed within established time frames.
- Schedule and maintain a time schedule for all interdisciplinary meetings and keep appropriate personnel informed of the schedule.
- Maintain the resident census on a daily basis.
- Maintain a current list of each physician’s residents and send to the physician quarterly.
- Pull charts for physicians’ rounds each week and insure that documentation is present.
- Monitor Restrain and Bowl and Bladder Programs to insure documentation is present.
- Audit MAR and Treatment sheets weekly.
- Audit Narcotic Count Sheets weekly.
- Review admission information for accuracy and completeness within 24 hours of admission.
- Conduct weekly audit of physician visits, progress notes, and nursing notes to insure that all signatures and dates are present.
- Conduct monthly audit of progress notes for all departments, monthly summaries, history and physical, etc. to insure that all forms are present and complete.
- Ensure that discharge records and chart are completed within 72 hours of discharge and arrange the file in chronological order in each section so that material can be retrieved in an efficient manner.
- File lab and x-ray reports on charts daily.
- Review physician orders (including telephone orders) and monitor to be sure that lab, x-ray, diagnostic tests, consultations, etc., have been scheduled and followed through.
- Maintain log/roster to identify when care plan meetings are due.
- Insure that MDS documentation is placed in resident’s medical record and that documentation is complete.
- Insure that MDS quarterly review sheets are completed with each care planning conference.
- Prior to admission, obtain the history and physical, admit orders, physician’s statement, TB skin test and/or chest x-ray.
- Maintain resident admission register and discharge list.
- Insure that a Facesheet is completed for each resident. Make copies of the form and distribute to the authorized personnel involved in the resident’s care.
- Prepare Resident Identifier and laminated name plate for the door for each new resident.
- Maintain a list of residents hospitalized and dates of hospitalization.
- Update individual hospitalization lists in charges including discharge summary from hospital.
- Maintain a file of incident reports and insure that the Director of Nursing and Administrator have seen and initialed the reports.
- Prepare a monthly summary of incident reports for review by the Director of Nursing and subsequently the Medical Director.
- Maintain a current list of diagnosis in each resident’s medical chart.
- Maintain a master list of all residents including length of stay.
- Prepare blank charts for admission if not utilizing electronic medical record.
- File discharged charts, QA reports, minutes of meetings, consultant reports (all departments).
- Prepare monthly report of deaths in the facility for Vital Statistics Department.
- Thin charts according to facility policies and arrange overflow in discharge chart order.
- Pick up and deliver lab specimens to the hospital.
- Deliver forms, physicians’ reports, etc. to clinics.
- Coordinate discharge and death records.
- Collect medical records upon discharge or death, assemble in proper order, and check for completeness.
- Return incomplete charts to nursing supervisor or attending physician for proper correction or completion.
- Retrieve medical records according to medical records policy & procedure & send to the Chief Compliance Officer (Policy on SharePoint/Corporate Compliance).
- Answer telephone inquiries and other correspondence.
- Maintain confidentiality of all medical records.
Equipment and Supply Functions
- Perform secretarial duties for committees of the facility as directed i.e., QAPI Committee, Safety, etc.
- Collect and assemble/compile records for committee review, as requested and prepare reports for staff/other committees as directed.
Staff Development Functions
- Maintain an adequate stock of medical forms and documentation supplies
- Report equipment malfunctions or breakdowns to your supervisor as soon as possible
- Assure that work/assignment areas are clean and records, files, etc. are properly stored before leaving such areas on break, end of work day, etc.
Safety and Sanitation Functions
- Attend and participate in in-service educational classes and on-the-job training programs.
- Conduct or coordinate at least one full staff in-service per year
Resident Rights Responsibilities
- Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately
- Maintain confidentiality of all pertinent resident care information to assure resident rights are protected
- 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
In return, we offer a comprehensive package for full time positions including medical, dental, vision, and matching 401(k). Excellent salary opportunities and growth potential. Come and grow with our company today!
- Works in office areas as well as throughout the facility.
- Moves intermittently during work hours.
- Is subject to frequent interruptions.
- Is involved with residents, personnel, visitors, government agencies/personnel, under all conditions and circumstances.
- Is subject to hostile and emotionally upset residents, family members, personnel and visitors.
- Communicates with the medical staff, nursing personnel and other department supervisors.
- Works beyond normal working hours and in other positions temporarily, when necessary. Works on weekends and holidays when necessary.
- Is subject to callback during emergency conditions.
- Attends and participates in continuing educational programs.
- Is subject to exposure to infectious waste, diseases, conditions, etc. including TB and the AIDS and Hepatitis B viruses.
- Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, plastics, synthetics, disinfectants, tobacco smoke, and other potential contaminants.
- May be subject to the handling of and exposure to hazardous chemicals.
- Must possess a high school diploma or GED/LPN preferred
- Some business training preferred
- Medical Records certification preferred
- Must have two (2) years’ experience in medical records.
- Must have a minimum of six (6) months of experience in a health care environment
- Must have a typing speed of 45 wpm or greater
- Must be familiar with both DOS and Windows computer environments
- Must have general office and clerical skills
- Must have excellent communication and interpersonal skills
- Must possess a practical knowledge of medical terminology and record keeping
- Must be organized and detailed in work performance
Physical and Sensory Requirements
- Must be able to read, write, speak and understand the English language.
- Must display professionalism both in appearance and attitude.
- Must possess the ability to solve problems and make independent decisions when circumstances warrant such action.
- Must genuinely care for and understand the elderly and disabled.
- Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agency personnel and the general public.
- Must possess the ability and the willingness to work harmoniously with other personnel.
- Must have patience, tact, a positive disposition and enthusiasm, as well as the willingness to handle difficult people.
- Must be knowledgeable of microcomputers, data entry, output, system applications, etc.
- Must possess the ability to examine and verify medical documents and reports.
- Must not pose a direct threat to the health or safety of other individuals in the workplace.
11-20 lbs. Continuously
- 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 be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
- Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
- Must meet the general health requirement set forth by the policies of this facility, which include a medical and physical examination.
- Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and at time hostile people within the facility.
- 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 five (5) pounds to a minimum height of three (3) feet and be able to push, pull, move, and/or carry such weight a minimum distance of five (5) feet.
- Must be able to assist in the evacuation of residents during emergency situations.
- Sitting: 1 hour per 8-hour shift. Alternates frequently to standing or walking.
- Standing: 1-2 hours per 8-hour shift. Alternates frequently to walking and occasionally to sitting.
- Walking: 5-6 hours per 8 hour shift. Alternates frequently to standing and occasionally to sitting.
- Lifting: 1-10 lbs. Continuously
21-75 lbs. Frequently
> 75 lbs. Frequently
11-20 lbs. Frequently
- Carrying: 1-10 lbs. Continuously
21-35 lbs. Occasionally
(Frequency: Never=0%; Rarely=1-10%; Occasionally=11=33%; Frequently = 34-66%; Continuously = 67%+)
- Driving: Rarely
- Pushing: Frequently
- Bending: Continuously
- Squatting: Frequently
- Kneeling: Occasionally
- Crawling: Rarely
- Climbing: Rarely
- Reaching: Continuously
- Grasping: Frequently
- Fine Manipulation: Frequently
Equal Employment Opportunity/Affirmative Action Employer and do not discriminate on the basis of race, color, age, sex, religion, national origin, disability, marital status, or any other characteristic protected by law.
Vanguard Healthcare Services - 12 months ago