Essential Job Functions: - Assist in organizing, planning & directing the medical records section in accordance with established policies and procedures.
- Maintain a working rapport with other departments in the facility to assure that medical records can be properly maintained.
- Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
- Collect, assemble, check, and file resident charts and personnel records as required.
- Ensure incomplete records/charts are returned to nursing service for correction.
- Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
- Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
- Maintain records of information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
- Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
- Maintain various registries as directed including register for admission and discharge of residents.
- Collect charts, assemble them in proper order, and inspect them for completion.
- Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
- Assist in admission, transfer and discharge procedures as necessary.
- Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
- Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies, etc.)
- Assure that medical records taken from the department are signed out and signed in upon return to the department.
- File active and inactive records in accordance with established policies.
- Index medical records as directed.
- Other duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.
Job type: Full-time or part-time |
