The Medical Records Clerk is responsible to maintain resident medical records and health information systems, in compliance with current federal and state guidelines, as well as in accordance with our facilities established privacy policies and procedures. He/She must be able to type a minimum of 50 words per minute and use dictation equipment. This position requires a wide variety of knowledge, including but not limited to, a working knowledge of; medical terminology, anatomy and physiology and the legal aspects of health information coding and indexing. Reporting to the Director of Nursing, the Medical Records Clerk will have experience in; medical record and health information system procedures; maintenance of medical records; and ICD-9-CM/DRG coding.
The ideal Medical Records Clerk will have one to two years relevant work experience and a high school diploma/GED. Must be a Certified Nursing Assistant, Medicine Assistant Technician, or Certified Medication Aide with experience in a nursing facility to be familiar with Oklahoma State licensure regulations for residential care.
The following is a representative list of duties and responsibilities associated with this position:
· Audits medical charts for timeliness and accuracy, according to policy and Oklahoma State regulations.
· Maintains and updates current information on each resident on a daily basis.
· Keeps staff informed about items needed in each resident’s chart in order to be in compliance with residential care regulations.
· Orders forms for computer system.
· Generates forms, prints medication and treatment records for each resident upon admission, and for DON, monthly.
· Makes corrections on computerized physician’s orders; prints physician’s orders monthly.
· Thins and audits resident records monthly, and files in resident folders.
· Annually, archives records previous to two years.
· Files miscellaneous records and forms.
· Responsible for closing and filing charts of discharged residents and store in ware house. Must be able to transport boxes to and from the ware house.
· Maintains confidentiality of resident records, services and communications.
· Assists in developing policy, procedures, and guidelines for resident care in area of medical records.
· Attends staff in-service training.
· Works cooperatively with other staff members using team approach.
· Practices safety at all times; applies all accident, fire safety or emergency procedures of the facility in compliance with Epworth Villa Policies and Procedures.
· May, on occasion, be pulled to work on the floor in an extreme staff emergency to ensure resident care.