Maintains medical records operations by following policies and procedures; reporting needed changes.
Initiates medical record by searching master patient index; identifying existing patient records or need to assign a new number; interacting with registration areas and physicians' offices for information verification; processing or creating the record folder.
Ensures medical record availability by routing records to admissions and emergency departments, physicians, and other authorized hospital staff; maintaining chart location systems.
Completes medical record by reviewing information; notifying health care providers of record deficiencies; tracking outstanding records; notifying medical director of physicians in jeopardy of losing admitting privileges.
Resolves medical record discrepancies by collecting and analyzing information.
Maintains historical reference by abstracting and coding clinical data, such as diseases, operations, procedures, and therapies, using standard classification systems; filing documents.
Prepares statistical reports by collecting and summarizing medical care and census information, such as types of diseases treated, surgery performed, and use of hospital beds.
Provides medical record information by answering questions and requests of patients, hospital staff, law firms, insurance companies, and government agencies.
Maintains patient confidence and protects hospital operations by keeping information confidential; following release-of-information protocols.
Maintains the stability and reputation of the hospital by complying with legal requirements.