The primary purpose of your job position is to assist the Charge Nurses in their day-to-day recording and charting of medical and/or administrative information.
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 an Admission Identification Summary is completed for each resident. Make copies of the form and distribute to the authorized personnel involved in the resident’s care Prepare ID bracelet 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 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 for authorized personnel upon request Answer telephone inquiries and other correspondence Maintain confidentiality of all medical records
Education Must possess a high school diploma or GED Some business training preferred Medical Records certification required Must have two (2) years’ experience in medical records.
Experience 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
(With or without the aid of mechanical devices) Must be able to move intermittently throughout the workday. 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 requirements 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 times, hostile people within the facility. Must be able to push, pull, move, and/or lift a minimum of 5 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 5 feet. May be necessary to assist in the evacuation of residents during emergency situations. Sitting: 3-6 hours per 8-hour shift. Alternates frequently to standing or walking. Standing: 2-3 hours per 8-hour shift. Alternates frequently to walking and occasionally to sitting. Walking: 1-3 hours per 8-hour shift. Alternates frequently to standing and occasionally to sitting. Lifting: 1-10 lbs. Continuously
11-20 lbs. Occasionally
21-35 lbs. Rarely
36-50 lbs. Rarely
51-75 lbs. Rarely
> 75 lbs. Rarely Carrying: 1-10 lbs. Continuously
11-20 lbs. Rarely
21-35 lbs. Rarely Driving: Rarely Pushing: Rarely Bending: Occasionally Squatting: Rarely Kneeling: Rarely Crawling: Rarely Climbing: Rarely Reaching: Occasionally Grasping: Occasionally Fine Manipulation: Continuously
(Frequency: Never=0%; Rarely=1-10%; Occasionally=11=33%; Frequently = 34-66%; Continuously = 67%+)
Equal Employment Opportunity/Affirmative Action Employer and does not discriminate on the basis of race, color, age, sex, religion, national origin, disability, marital status, or any other characteristic protected by law.