Overview

Health Information Management Clerk works with the medical record to ensure complete, accurate and timely completion of the medical record.

The HIM Clerk also release protected health information in accordance with State and Federal rules and regulations. The HIM Clerk position is a customer service position.

Responsibilities

Service

• Telephone Skills : Demonstrates hospital telephone etiquette by answering phones promptly, courteously, and by identifying department and self courteously, and by identifying
• Customer Service : "Attitude is Everything" motto. Takes personal responsibility for providing quality services every day.

Displays customer service skills by greeting all customers warmly, making eye contact, introducing self, providing assistance needed in a friendly and caring manner.

• Confidentiality : Sensitive information including, but not limited to, patient records, charts, hospital documents, and employee information is kept confidential.
• Chain of Command : Communicates well with supervisor, reporting problems with equipment, supplies, or procedures. Requests assistance as appropriate.
• Patient Rights : Respects the rights and privacy of all patients and customers.

People

Teamwork : Promotes positive co-worker relationships through teamwork and cooperation. Understands and supports the needs of individuals in other departments and promotes conflict resolution.

Shares information, work knowledge and experience with co-workers, physicians, and students in a non-threatening manner.

Offers assistance and promptly responds to requests.

• Appearance : Projects a professional image. Follows the hospital dress code policy and / or Department requirements. Wears hospital ID badge at all times while on duty.
• Annual Requirements : Completes annual requirements on time (PPD, Annual Update, ethics training, licensure and / or professional certification) as well as annual Safety updates.
• Staff Meetings : Participates actively in department staff meetings, attending 80% of meetings.

Quality

• Policies / Procedures : Is aware of and follows all hospital and departmental policies and procedures.
• General Work Habits : Readily accepts work assignments in a positive manner.
• Safety : Keeps work area neat and maintains equipment in accordance with health and safety codes. Reports safety issues and equipment and consistent.

Growth

• Identifies Opportunities : Communicates opportunities to improve care of service.
• Employee Goals : Establishes yearly goals that will enhance personal job performance.
• Participates / Supports New Initiatives : Tries new approaches to problem solving, reaching goals, and / or new programs.

Cost

Attendance : Employee reports to work each regularly scheduled work day. Accurately records all work time including meal period.

No more than two written counselings since last evaluation.

• Punctuality : Is ready for work at precise starting time and continues working until scheduled departure time. Returns on time from all meal period.
• Fiscal Responsibility : Utilizes human and material resources of the organization responsibility.

Birth Clerk Assistant

Assists Birth Clerk in completing birth certificate worksheets for all butes certificate worksheet. Answers patient questions.

Collects certificate worksheet.

Assists Birth Clerk in obtaining signatures from parent and delivering physician and completes letter of verification for all patients who deliver.

Reviews official document with patient and obtains patient signature for birth clerk. Obtains physician signature if he or she is present.

• Assists Birth Clerk in explaining POP program to potential legal fathers. Explains paternity opportunity program (POP) to potential legal fathers.
• Assists Birth Clerk in applying for SSN for newborns. Fills out paperwork for SSN for newborns.
• Assists Birth Clerk in responding to customer's requests within one business day. Uses proper phone etiquette and customer service skills 100% of the time.
• Assists Birth Clerk in issuing gift certificates. Logs gift certificate and issues on behalf of gift shop for birth clerk.
• Assists Birth Clerk in following up with discharged patients as needed. Contacts patient who left and schedules appointments for birth clerk.

Pull Charts

• Responsible for Coding Audit record pulls. Pulls records daily for Case Management record requests.
• Responsible for other record pulls as requested. Pulls records daily for ad hoc record requests.

Special Record Requests

• Responsible for Case Management record pulls. Pulls records daily for Case Management record requests.
• Responsible for Committee record pulls. Pulls records daily for Committee record requests.
• Responsible for Department record pulls. Pulls records daily for Department record requests.
• Responsible for Quality record pulls. Pulls records daily for Quality record requests.
• Responsible for TARS record pulls. Pulls records daily for TARS record requests.

Concurrent Analysis

Ensures an H&P is completed within 24 hours of admission and prior to surgery. Tracks physician responsible for missing reports / document.

Findings are documented within 3 days.

Ensures an Operative report is completed immediately after surgery (Day of surgery) for GI, AS, and Surgery. Tracks physician responsible for missing report / document.

Findings are documented within 3 days.

• Tracks concurrent analysis findings. Maintains log within three (3) days of event. Tracks physician responsibility for missing H&P's and Operative reports in Excel workbook and saves to shared drive.
• Customer Service. PRN-answers within 3 rings; uses proper phone etiquette and customer service skills 100% of the time.
• Other functions necessary for departmental operations. PRN-provides support as needed.

Customer Service

• Answers phones. Answers within 3 rings, uses phone etiquette and customer service skills 100% of the time.
• Maintains phone log. Documents incoming voicemail and follow up call (every 1 hour).
• Assists patients, patients' family and visitors. Provides immediate assistance; demonstrates appropriate customer service skills 100% of the time.

Sorts and distributes incoming USPS mail.

• Files all incoming loose sheets. Files all incoming loose sheets in appropriate records. Monthly standard is less than 5 compressed inches.
• Other functions necessary for departmental operations. PRN-provides support as needed.

Incomplete Record Management Day Shift

• Run deficiency reports. Print deficiency report with physician's pull list at start of shit. Print unsigned electronic sign at start of shift.
• Pulls for next day physicians and delivers to appropriate areas. Also, picks up yesterdays incomplete medical records.

This is performed on Eve Shift. Day shift covers when Eve shift is scheduled off. Ensures incomplete medical records for physicians and anesthesiologist on surgery schedule and GI schedule are pulled taken to OR lounge.

Ensures incomplete medical records for emergency physicians on schedule for next day are taken to emergency dept. Ensures incomplete medical for radiologist scheduled for next day are taken to reading room in radiology dept.

Picks up yesterdays incomplete medial records left in all areas prior to end of shift daily.

Pull charts for physicians. When a physician request their medical records be pulled because they are going to come in to dept.

Pulls records for physician and reminds physician to eSign in CPSI when they come in.

Log physician's visit. Update Excel workbook with physician's visit date. Includes comments if any. Updates vacation / sick log too.

Also, log known IS tickets for physician eSign (CPSI issues).

Faxes to physicians for completion. A copy is made of the incomplete medical record. The copy is faxed with a coversheet to the physician requesting he or she complete and fax back.

Same process for USPS mailing to physician for completion, includes return envelope.

Clears and / or updates deficiencies in CPSI. Average 30 seconds per deficiency for updates / clearing of medical records.

Completes task before end of shift daily. Includes clearing after physician visit and after physician fax back. Includes updating deficiencies after physician dictates and again after physician eSigns in CPSI.

• Files medical records into proper locations. Files medical record to proper location using chart tracking system. Checks chart against records pulled before putting on incomplete file if records pulled adds to physician's stack.
• Maintains Suspension List. Daily updates suspension list. Documents totals at bottom of form when physician is removed.

Daily distributes suspension list.

Completes audit of incomplete records. Performs audit of incomplete records area on a quarterly basis.

Incomplete Record Management Eve Shift

Run deficiency reports. Done by both shifts if needed. Print deficiency report with physician's pull list at start of shit.

Print unsigned electronic sign at start of shift.

Pulls for next day physicians and delivers to appropriate areas. Also, picks up yesterdays incomplete medical records.

This is performed on Eve Shift. Day shift covers when Eve shift is scheduled off. Ensures incomplete medical records for physicians and anesthesiologist on surgery schedule and GI schedule are pulled taken to OR lounge.

Ensures incomplete medical records for emergency physicians on schedule for next day are taken to emergency dept. Ensures incomplete medical for radiologist scheduled for next day are taken to reading room in radiology dept.

Picks up yesterdays incomplete medial records left in all areas prior to end of shift daily.

Pull charts for physicians. Done by both shifts as needed. When a physician request their medical records be pulled because they are going to come in to dept.

Pulls records for physician and reminds physician to eSign in CPSI when they come in.

Log physician's visit. Done by both shifts as needed. Update Excel workbook with physician's visit date. Includes comments if any.

Updates vacation / sick log too. Also, log known IS tickets for physician eSign (CPSI issues).

Faxes to physicians for completion. Done by both shifts as needed. A copy is made of the incomplete medical record. The copy is faxed with a coversheet to the physician requesting he or she complete and fax back.

Same process for USPS mailing to physician for completion, includes return envelope.

Clears and / or updates deficiencies in CPSI. Done by both shifts as needed. Average 30 seconds per deficiency for updates / clearing of medical records.

Completes task before end of shift daily. Includes clearing after physician visit and after physician fax back. Includes updating deficiencies after physician dictates and again after physician eSigns in CPSI.

Files medical records into proper locations. Done by both shifts as needed. Files medical record to proper location using chart tracking system.

Checks chart against records pulled before putting on incomplete file if records pulled adds to physician's stack.

Maintains Suspension List. Done by both shifts as needed. Daily updates suspension list. Documents totals at bottom of form when physician is removed.

Daily distributes suspension list.

Completes audit of incomplete records. Done by both shifts as needed. Performs audit of incomplete records area on a quarterly basis.

Assembly / Analysis Ambulatory Surgery, GI Surgery

Files all incoming Ambulatory into appropriate accordion folder. Scans documents into CPSI.

• Filing of all Ambulatory loose sheets. Files all incoming Ambulatory loose sheets in appropriate record.
• Locates missing records within 72 hours of discharge. Follows up daily for records not received. Maintains / updates Ambulatory log via email and notifies respective department of missing records so accounts can be coded in a timely manner.
• Customer Service. PRN-answers within 3 rings; uses proper phone etiquette and customer service skills 100% of the time.
• Other functions necessary for departmental operations. PRN-provides support as needed.

Correspondence / Release of Information

Performs release of information function for patients, patients' family, and visitors. Provides copies (prints) of patient medical record within state and federal guidelines.

Completes requests within 3 working days.

Performs release of information functions for all requests from outside agencies (Attorneys, Subpoenas, Physicians, Hospitals, Insurance companies, CBO, TARS, etc) Releases patient information in accordance with rules and regulations concerning confidentiality.

Completes requests within 5 working days.

• Orders charts located at off-site storage vendor. Ensures off-site medical records are ordered prior to 3pm each day for next day delivery prior to 4 : 30pm Monday through Friday.
• Uses correspondence application to log in requests. Tracks information pertaining to release of information and copy services;

Collects fees for copying; Logs records and mails reports; Files records after copies are made. Completes log day record are copied (printed) Standard : 35 charts per day.

• Customer Service. PRN-answers within 3 rings; uses proper phone etiquette and customer service skills 100% of the time.
• Other functions necessary for departmental operations. PRN- provides support as needed.

Suspension Process Day Shift

Reminds physician of incomplete and / or delinquent medical records. Phone calls are done by both shifts as needed. Call physician on Thursday and / or Friday reminding physician of need to complete incomplete and / or delinquent record in order to avoid suspension and gives next suspension date.

Documents phone call with name of person who spoke with and date and time of call, and summary of discussion. Calls physician on suspension, and those who received warning and overdue letters.

Prepares for suspension on Wednesday. This is performed on Day Shift. Eve shift covers when Day Shift is scheduled off.

Physicians who received a letter and phone call the prior week and have delinquent medical record(s) are subject to suspension and are reviewed for possible suspension.

Indicates if physician was on vacation, sick, has open CPSI ticket for eSign, and date of last visit. For surgeons, date next on surgery schedule.

For ER physicians, date next on ER schedule. Presents physician to director for determining of suspension.

Prepares weekly letters. This is performed on Day Shift. Eve shift covers when Day Shift is scheduled off. Folding of letters is done by both shifts as needed.

Overdue letters are prepared first, suspension letters are prepared next, followed by warning letters, followed by reminder letters.

Faxes suspension letters and USPS mails. USPS mails other.

Maintains Suspension List. This is performed on Day Shift. Eve shift covers when Day Shift is scheduled off. Updates suspension list every Thursday with new additions and / or any removals.

Documents totals at bottom of form when physician is removed. Updates totals on list. Distributes newly current Suspension List for week.

Suspension Process Eve Shift

Reminds physician of incomplete and / or delinquent medical records. Phone calls are done by both shifts as needed. Call physician on Thursday and / or Friday reminding physician of need to complete incomplete and / or delinquent record in order to avoid suspension and gives next suspension date.

Documents phone call with name of person who spoke with and date and time of call, and summary of discussion. Calls physician on suspension, and those who received warning and overdue letters.

Prepares for suspension on Wednesday. This is performed on Day Shift. Eve shift covers when Day Shift is scheduled off.

Physicians who received a letter and phone call the prior week and have delinquent medical record(s) are subject to suspension and are reviewed for possible suspension.

Indicates if physician was on vacation, sick, has open CPSI ticket for eSign, and date of last visit. For surgeons, date next on surgery schedule.

For ER physicians, date next on ER schedule. Presents physician to director for determining of suspension.

Prepares weekly letters. This is performed on Day Shift. Eve shift covers when Day Shift is scheduled off. Folding of letters is done by both shifts as needed.

Overdue letters are prepared first, suspension letters are prepared next, followed by warning letters, followed by reminder letters.

Faxes suspension letters and USPS mails. USPS mails other.

Maintains Suspension List. This is performed on Day Shift. Eve shift covers when Day Shift is scheduled off. Updates suspension list every Thursday with new additions and / or any removals.

Documents totals at bottom of form when physician is removed. Updates totals on list. Distributes newly current Suspension List for week.

Qualifications

• Education : High school diploma or equivalent, enrollment in registered health information technology program preferred.
• Experience : Minimum of two years HIM (Medical Record) experience preferred.
• Required Certification / Registration : N / A
• Professional Requirements : Medical terminology; ability to pass departmental skills testing exam.

Last updated : 2024-07-02