SUMMARY

Responsible and accountable for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long-term care facilities.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

§ Prepares charts for new admissions.

§ Closes medical records upon discharge.

• Develops schedule for and conducts audits of the clinical and electronic health records.

• Monitors physician visit schedule.

• Maintains master index system.

• Orders, maintains, and distributes medical records forms.

• Monitors procedures to maintain confidentiality of patient information and guard against loss or destruction of data in accordance with the facility’s policy and procedures.

• Maintains records and completes required forms and documents in accordance with facility policies and state and/or federal regulations.

ENTRY QUALIFICATIONS

• High school diploma or equivalent.

• Working knowledge of medical terminology.

• Proficient in the use of personal computer.

SUPERVISORY RESPONSIBILITIES

Supervises Medical Record assistant, if any, and others for whom they are administratively or professionally responsible.

WAGE RATE FROM $18.00 TO $20.00 AN HOUR DEPENDING ON EXPERIENCE