Job Description and Responsibilities :

The primary purpose of this position is to maintain medical records in accordance with federal and state guidelines, and in accordance with our policies and procedures, to assure that a complete medical records program is maintained.

Responsibilities:

• 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.

• Index medical records as directed.

• Other duties and responsibilities that may become necessary or appropriate to meet the administrative needs of the facility.

Job Snapshot