SUMMARY

Medical Records Coordinator is responsible for the maintenance and retention of medical files for patients and residents in accordance with the Indiana State Department of Health. MRC must stay up to date on new laws including but not limited to, Medicare, Medicaid, Dept. of Health, HIPAA, Elder Justice, etc. MRC is also responsible for an array of other tasks such as auditor and coordinator of electronic charting, census reports, and immunization records.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Implementation of Point Click Care – Lead Point Click Care Coordinator, assist with troubleshooting, set up user permissions, clinical assessments, and upgrades. Support contact person and staff educator of system. Contact person 24/7 for all Point Click Care issues. Electronic MAR/TAR/Progress Notes/24 Hour Report/Clinical Assessments/Care Plans and MDS’s – Oversee order writing, reconciliation of orders, schedule confirmation, missed or late documented medication/treatment administrations and monitoring follow up documentation, completion of clinical assessments, demographic information/changes, diagnosis, medical alerts and allergy reviews. Shift and Task Sign off reviews completed daily. Monitoring and tracking physician orders for all physician’s/review/approve all orders monthly.

Admission chart – prepare chart with each admission and distribute to Director of Business Development and/or Admissions Coordinator. Obtain photograph of newly admitted resident within 48 hours to be downloaded to EMAR. Point Click Care demographics checked with resident credentials for accuracy in transposition.

Admission Audit – completed within 24-48/72 hours after admission and re-audit within (14) days after admission, which includes initial departmental assessments, completed, and immunization including flu, pneumonia, and Mantoux. Initial nurse entries, vitals, Medicare certifications, diagnoses, 450-B certifications and Level I accounted for on chart, and review Advance Directives.

On-going Audits – correctable chart audits: physicians, nursing staff and other health care professionals to flag these deficiencies for completion by the appropriate persons, audit records on a regular basis for omissions in documentation.

Physician Visit Schedule – to ensure physicians are in compliance with our facility policy every 30/60/90 and 60 days thereafter.

Immunization Records – track PPD’s, Flu, Pneumo-vax and Shingles vaccinations per state regulations/guidelines as recommended by the CDC for all residents.

Thinning/filing – Quarterly, all charts require thinning of Physician Orders, Pink Progress Notes, Telephone Orders, Controlled Substance Record, Nurses Notes, MAR,TAR, Behavior/Intervention Monthly Flow Record, Glucose and IV records, Therapies, I&O records,

Telephone orders – Sort, track and mail every two weeks for physician signature and distribute and place on charts after signed and returned. PCC P.O.’s are printed monthly for physician signature.

Order - Forms that are needed through vendors; When needed, these forms are ordered and tracked through P.O and approved by CFO or DON prior to ordering.

Quality Assurance – Compile material from three month period for QA quarterly Compliance meeting including issues identified needing to be addressed by IDT team.

Other Responsibilities – Any other responsibilities as assigned by supervisor.

SUPERVISORY RESPONSIBILITIES

N/A

QUALIFICATIONS

Must pass OIG and limited criminal history background check.

EDUCATION AND EXPERIENCE

Long-term care experience preferred.

PHYSICAL DEMAND

• Will need to be able to stand and sit for extended periods of time, bend, twist and reach to the floor.
• Must be able to clearly speak at a volume adaptable to the hearing impaired.
• Lifts and carries equipment weighing 25 pounds.