WARD CLERK

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.