ED Chart Processor - Health Information Management

MAIN FUNCTION:

Convert hard copy Emergency Room records to electronic format. Performs a limited quantitative review of all Emergency Room medical records managed by HIM for the purpose of compliance with guidelines established by the Arnot Health, in accordance with state, federal and accrediting agencies. Reports to HIM Manager as designated by the System Director Health Information Services.

DUTIES AND RESPONSIBILITIES:

1. Performs a review of both the electronic portion and hard copy portion of the medical record for completion of Emergency Department. Identifies, flags, and lists all chart deficiencies and assigns them to the responsible provider within a 3 day timeframe to comply with chart completion standards and regulations.

2. Maintains file management of the Emergency Department medical records: files records, retrieves records, and scans paper records to electronic format.

3. Scans Ambulance/ EMS records as received from the outside agencies. These are scanned for immediate use by the health care team.

4. Completes deficiencies on Emergency Department charts as appropriate.

5. Reviews charts to assure that proper discharge arrangement of the chart is met.

6. Functions as scanning lead for quality review and scanning corrections.

7. Follows up on the Billing/SPARCS list to ensure compliance. Works with ED staff and ED providers to complete records timely.

8. Works closely with the ED Coding department to process requests for documentation as needed to complete coding.

9. Scans loose filing into the electronic medical records as appropriate.

**10. Is responsible for keeping HIM Manager/Director abreast of status of incomplete records and identifies areas of concern for delinquent medical records.

**11. Assists in providing completed physician documentation as requested internally.

**12. Stays abreast of all current state, federal, and other regulatory agency requirements of medical records documentation.

13. Is cross-trained to back up the Incomplete Chart Processor and Inpatient/ Day Surgery Analyzers.

14. Utilizes the Hospital Clinical System for proper chart tracking including:

• Locates charts.
• Signs-out charts.
Checks charts into the correct location.

15. Assists physicians with electronic signature.

16. Assists customers with completion of Authorization forms but does not release records to patients unless directed by the Correspondence Coordinator. Authorized to release medical information to healthcare providers and facilities in medical emergencies.

17. Answers phones, assists customers from the Emergency Department, physicians, units, and ancillary personnel as requested.

18. Provides coverage for clerical area with other clerical team members.

• Waits on physicians in the incomplete chart area
• Copies records for transfers
• Pulls charts as requested by units and Emergency Department
• Performs timing and tagging functions as necessary
Scans discharge charts.

19. Maintains confidentiality of all medical record information.

20. Is responsible for attending mandatory educational programs as required by position.

21. Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer in order to provide a secure and pleasant experience with the Arnot Health.

22. It is understood that this job description lists typical duties for the classification and is not to be considered inclusive of all duties, which may be assigned.

EDUCATION:

High School graduate. Medical terminology required. Medical Office Assisting, Health Information Technology, or comparable degree preferred.

EXPERIENCE:

Clerical and/or office experience required. Computer experience required. Medical office/unit experience preferred.

CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:

No CPR required.

PHYSICAL DEMANDS:

Moderate physical effort. Must be able to lift 30 lbs. Typical office job. On feet a moderate amount of time.

EXPOSURE CATEGORY:

Category III. Tasks that involve no exposure to blood, body fluids, or tissues. Category I tasks are not a condition of employment

*A.D.A. Essential Functions