Medical Records

Purpose of Your Job Position

The primary purpose of your job is to maintain medical records in accordance with federal and state guidelines, especially HIPAA/HITECH, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained; to maintain inventory levels; and to update all computer-generated forms and information.

Delegation of Authority

As the Medical Records Director, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Duties and Responsibilities

Administrative Functions

Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.

Maintain at all times compliance HIPAA/HITECH.

Assist in organizing, planning and directing the electronic medical records and hard files section in accordance with established policies and procedures.

Function as HIPAA Privacy Officer in relation to Medical Records

Assist in the orientation program for all personnel in accordance with our policies and procedures.

Maintain minutes of meeting/files as necessary.

Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.

Assist in recording all incidents/accidents and file in accordance with established policies and procedures.

Collect, assemble, check and file electronic resident charts and personnel records as required. Ensure that schedules are followed as outlined for respective shift/area.

Ensure that nursing is notified of incomplete records/charts for correction.

Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc. before filing.

Follow established policies and procedures for the electronic medical records section. Establish a procedure to ensure charts/records do not leave the section or are edited in the system except as authorized in our policies and procedures.

Maintain a record of authorized 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.

Index medical records as directed.

Maintain various registries as directed including register for admission and discharge of residents.

Type reports for physicians as necessary.

Assemble electronic medical records 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 and personnel, etc.

Assure that any hard copy 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 electronic and hard copy medical records as directed.

Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Director.

Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.

Committee Functions

Perform secretarial duties for committees of the facility as directed.

Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.

Actively participate in Facility QAPI and QA Committees.

Staff Development

Attend and participate in in-service educational classes and on-the-job training programs including annual OSHA and CDC in-service training programs concerning hazards, communication, TB management, HIPAA/HITECH, and bloodborne pathogens and quarterly Corporate Compliance training.

Attend and participate in workshops, seminars, etc. as approved.

Safety and Sanitation

Report all unsafe/hazardous conditions, defective equipment, etc. to your supervisor immediately.

Resident Rights

Maintain confidentiality of all pertinent resident care information to assure resident rights are protected.

Knock before entering a resident's room.

Assure that residents' right to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints are followed.

Working Conditions

Works in office areas, as well as throughout the facility.

Moves intermittently during work hours.

Is subject to frequent interruptions.

Works beyond normal working hours, weekends and holidays and on other shift/positions as necessary.

Is subject to call-back during emergency conditions (e.g. severe weather, evacuation, post-disaster, etc.).

Attends and participates in continual educational programs.

Is subject to injury from falls, bums from equipment, odors, assaults from hostile residents, etc. throughout the work day, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

Communicates with the medical staff, nursing personnel, and other department supervisors.

Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.

Is involved with residents, family members, personnel, visitors, government agencies and personnel, etc.

May be subject to the handling of and exposure to hazardous chemicals.

Maintains, and acts as a liaison with the residents, their families, support departments, etc., to adequately plan for the residents' needs.

Education Requirements

Must possess, as a minimum, a high school diploma.

Experience

Must be able to type a minimum of words per minute, use dictation equipment, and have a working knowledge of medical terminology.

On-the-job training provided in medical record procedures.

Specific Requirements

At least 2 years experience.

Must be able to read, write, speak, and understand the English language.

Must possess the ability to make independent decisions when circumstances warrant such action.

Must possess the ability to deal tactfully with personnel, residents, visitors and the general public.

Must be knowledgeable of medical terminology.

Must have a good working knowledge of HIPAA/HITECH regulations and state privacy laws

Must possess the ability to work harmoniously with other personnel

Must possess the ability to minimize waste of supplies, misuse of equipment, etc.

Must be willing to seek out new methods and principles and be willing to incorporate them into existing practices.

Must be able to follow oral and written instructions.

Must be knowledgeable in micro-computers, data input and output.

Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc. that are necessary for providing quality care.

Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.

Must not pose a direct threat to the health or safety of other individuals in the workplace. Must be dependable, self-starter and work independently at times.

Physical and Sensory Requirements

(With or Without the Aid of Mechanical Devices)

Must be able to move intermittently throughout the work day.

Must be able to speak and write the English language in an understandable manner. Must be able to cope with the mental and emotional stress of the position.

Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of the position can be fully met.

Must function independently, have flexibility, personal integrity, and the ability to work effectively with other personnel.

Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination.

Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and at times hostile people within the facility.

Must be able to push, pull, move, and/or lift a minimum of 35 lbs. to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 450 feet.

May be necessary to assist in the evacuation of residents during emergency situations.