Medical Records

JOB TITLE: MEDICAL RECORDS

JOB CODE: 29

DEPARTMENT: NURSING

FLSA STATUS: NON-EXEMPT

REPORTS TO: DIRECTOR OF NURSING

JOB SUMMARY: Under the supervision of the professional nurse, performs a variety of clerical duties associated with patient care unit operations.

ESSENTIAL FUNCTIONS:

• Written and verbal communication with members of the healthcare team, patients, and visitors utilizing equipment such as the telephone and intercom
• Maintain confidentiality of patient information
• Assemble, complete, and process patient charts as indicated
• Keep patient records accurately identified; maintain an accurate clinical record, recording information per facility policy
• Transcribe doctors’ orders per facility policy
• Perform daily review of charts for incomplete histories and operative summaries; bringing any compliance issues to the attention of the appropriate member of the health care team for correction
• Obtain closed records from Medical Records as needed
• Initiate required nursing forms for new admissions and at month end
• Order unit supplies to maintain inventory stock and supplies; assist with receiving, distributing and sorting supplies brought to the unit
• Maintain an orderly and businesslike environment at the nursing station in order to assist members of the health care team in the performance of their jobs despite high-stress factors
• Promote positive public relations with patients, residents, family members, and guests
• Use tactful, appropriate communications in sensitive and emotional situations
• Use appropriate workplace behavior and adhere to dress code at all times
• Understand and adhere to the guidelines of “Residents Rights” and assure resident safety
• Other duties as assigned

QUALIFICATIONS:

Required

• High school diploma or equivalent (GED)
• Ability to type
• General computer knowledge
• Good written and verbal communication skills

Preferred

• PCC & SimpleLTC software
• Prior experience entering orders into computer
• Knowledge of medical terminology
• Good written and verbal communication skills

PHYSICAL REQUIREMENTS: The ability to safely perform movements such as pushing, pulling, lifting, bending, kneeling, and reaching up to 25 pounds with or without reasonable accommodations

WORK SCHEDULE: As assigned, including some weekends, evenings and holidays

WORK ENVIRONMENT: General Office

Caraday Healthcare provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other characteristic protected by law.