In order to fulfill the job functions listed below an individual must meet the following minimum qualifications.

Communicate effectively in person, on the telephone, and in writing.

Possess a High School diploma or equivalent.

*Proficiency in computers, including current FMCF Charting Software and Outlook-365 Encryption

*Possess computer word processing skills.

*On year experience in medical terminology, medications (understanding basics of Pharmacology), transcription, computer data entry, filing, sorting and record keeping (Preferred).

Minimum of one year experience in the medical record field (Preferred).

*These qualifications will be skill tested. Minimum requirements must be demonstrated to be awarded the positions.

REQUIREMENTS

Comply with all Facility policies and procedures.

Comply with all policies and procedures as may be established by your Director.

Comply with all safety, universal precautions and infection control policies and procedures.

Present a friendly, calm, cooperative, positive manner.

ESSENTIAL JOB FUNCTIONS

On occasion may need to lift up to 40 lbs.

Prompt and regular attendance.

Assist nurses to proofread physician’s orders; carry out physician’s orders and check for signatures; make copies

for pharmacy and deal directly with Pharmacy.

Update orders in nursing computer; update and proofread resident medication administration records (MAR)

and treatment administration records (TAR).

Update diets and check for accuracy.

Assist with in-house resident transfers, notifying all departments and changing records as appropriate.

Assist with admissions and with emergency transfers to ER.

Prepare appropriate forms for resident admission and discharge; assure all required information is included in

chart from the admission checklist; assemble admission record and record information. Prepare orders for

signature via encrypted Outlook-365 email to remote Physician practices.

Prepare orders for signature via encrypted Outlook-365 email to remote Physician practices.

Schedule resident appointments outside the Facility; prepare appropriate paperwork to accompany to resident,

coordinated transportation for appointment.

ESSENTIAL JOB FUNCTIONS (CONTINUED)

Schedule lab; complete lab slips for local hospital’ prepare lab list for upcoming lab day and call in or fax to local

hospital; prepare x-ray requests forms for portable unit and notify hospital.

Verify all code status and allergies to assure they are accurately posted in resident’s chart. Room, wristband and

computer.

Prepare name bands for residents, place ID tags on chart, place allergy tags on chart; place O2 signs; replace ID’s as necessary.

Fax messages to physicians and fax medication list to pharmacy

Transcribe physician dictation to include residents history and physical, discharge summary, progress notes,

care plans; transcribe other correspondence/reports.

Chart monthly TPR’s, weights in resident charts and MD progress notes.

Check labs to be performed every two months via computer and index card.

Prepare new forms for the month, including Physicians order, MAR’s and TAR’s.

Assist residents returning from appointments; review orders received.

Return completed charts to Medical Record Department.

Maintain and control release of information of medical records per procedure.

File all lab reports & x-rays on charts; make copies of faxed able results and file in charts & scan to computer.

Update I & O, BM list, feeding list and 24-Hour Report weekly.

Prepare new vital signs sheet, weight sheet and O2 log sheet.

Check flow sheets for blank spaces and signatures; replace new flow sheets and folders as necessary.

Review contents of medical record and purge according to procedure.

Take accurate telephone messages for supervisors and residents.

Assist residents, as needed, when making personal telephone calls.

Assure adequate supply of forms and supplies are in desks and drawers.

Place blank physician’s orders and nursing notes in charts as needed.

Purge archives of records to be destroyed.

Shred confidential material as needed.

Maintain confidentiality.

Requisition supplies, as needed.

Maintain clean, orderly, and safe work environment.

Immediately report malfunctioning or unsafe, or suspected malfunctioning or unsafe, equipment or conditions

to supervisor.

Attend required in-services and required meetings.

Other duties may be assigned.