Under the general supervision of the Administrator, and in compliance with all applicable
organizational policies, standards and regulatory requirements, the individual is responsible for
maintaining medical records to document history, treatments and orders, and to identify, compile,
abstract and code patient data using standard classification systems.
• Protects the security of medical records to ensure that confidentiality is maintained.
• Reviews records for completeness, accuracy and compliance with regulations.
• Compiles and maintains patients' medical records to document treatment, physician
orders, nursing notes, etc.
• Enters data, such as demographic characteristics, history and extent of disease,
diagnostic procedures and treatment into computer.
• Plans, develops, maintains, and operates a variety of health record indexes and storage
and retrieval systems to collect, classify, store and analyze information.
• Identifies and compiles patient data using standard classification systems.
• Resolves/clarifies codes and diagnoses with conflicting, missing, or unclear information
by consulting with the nursing facility staff or others to get additional information
• Purges records as per policy
• Orders & receives office supplies and medical forms, journals, books, etc.
• Participates in staff meetings and new employee orientation and training programs.
• Performs maintenance functions for the department computer system.
• Assists in maintaining and fostering customer relationships.
