Douglas Cove Health and Rehabilitation -
Medical Records, Central Supply, Scheduler
Summary :
Administer the distribution and inventory of resident care supplies in accordance with facility policies and procedures, maintain residents’ medical records in accordance with facility policies and with state and federal regulations, as well as maintaining nursing department work schedule.
Environment :
Work will be performed primarily indoors at one of our long-term healthcare facilities, throughout all areas, including in resident rooms, and on carpeted and / or tiled floors. Work will be performed there routinely around other co-workers, healthcare staff, residents, and guests. Due to the nature of facility’s business, worker may be exposed to occasional slippery floors, object on floors, chemicals, sharp objects, hazardous materials and waste (including human), blood borne pathogens, and communicable diseases, as well as high-stress medical and / or life-threatening situations.
Essential Duties & Responsibilities :
- Meet physical and sensory requirements stated below, and be able to work in the described environment.
- Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and / or improve the work environment.
- Organize and maintain facility medical records system in compliance with corporate, state and federal regulations.
- Inventory and stock supplies maintained at nurses’ station in supply points, distribute appropriate supplies; record inventory.
- Inventory and monitor central supply levels.
- Order, receive, and restock in accordance with procedures.
- Secure emergency or critical items.
- Review crash cart daily and restock with each use.
- Monitor cost and maintain related records.
- Assist with Nursing Department activities to include administrative support; assisting residents, families, and visitors, and running errands to include travel to supply sources.
- Assist with preparing nursing department work schedules for each calendar month and find call-in replacements in order to meet corporate, state, and federal staffing guidelines.
- Assist Medical Records in pulling charts for physicians’ rounds each week.
- Answer phones, assist visitors and residents and relay communications.
- Perform clerical tasks to include processing administrative transfer and discharges.
- Carry out additional administrative support, which may include maintaining medical records, assisting with scheduling or job assignment, and preparing special reports.
- Ensure that IV poles and oxygen equipment is properly cleaned and stored after use.
- Maintain a safe and orderly work area.
Other special projects and duties, as assigned.
Code and quantify records from admission to discharge.Maintain a documented, organized system, which is readily accessible by other authorized professionals.Ensure that all reports are completed within established time frames.Maintain the resident census on a daily basis.Maintain a current list of each physician's residents and send to the physician quarterly.Pull charts for physicians' rounds each week and ensure that documentation is present.Monitor Restraint and Bowel & Bladder Programs to ensure documentation is present.Audit MAR and Treatment Sheets weekly.Audit Narcotic count sheets weekly.Perform chart audits as follows :Admission audit – twenty four (24) hours after admissionWeekly audit of physician visits, progress notes, and nursing notes to ensure that all signatures and dates are present.Monthly audit of progress notes for all departments, monthly summaries, history and physical, etc., to ensure that all forms are present and completed.Discharge audit - chart is to be complete within seventy two (72) hours including discharge summary and arrangement in chronological order in each section of the chart so that material can be retrieved in an efficient manner.File lab and x-ray reports on charts daily.Review physician orders (including telephone orders) and monitor to be sure that lab, x-ray, diagnostic tests, consultations, etc., have been scheduled and followed through.Maintain log / roster to identify when care plan meetings are due.Ensure that MDS documentation is placed in resident's medical record and that documentation is complete.Ensure that MDS quarterly review sheets are completed with each care planning conference.Schedule care plan meetings.Notify family and staff thirty (30) days in advance of care plan meeting, fifteen (15) days in advance and one (1) week in advance.Obtain the following information for admission of a new resident : History & Physical, Admit orders, Physician's Statement (Part of PAE), TB skin test and / or chest x-ray.Prepare ID bracelet and laminated name for the door for each new resident.Maintain a list of residents hospitalized and dates of hospitalizations.Prepare blank charts for admissions.File discharged charts, QA reports, minutes of meetings, and consultant reports (all departments).Thin charts according to facility policies and arrange overflow in discharge chart order.Maintain adequate stock of medical forms and documentation supplies.Coordinate discharge and death records.Collect medical records upon discharge or death, assemble them in proper order, and check for completeness. Incomplete charts are returned for proper correction or completion to nursing service or attending physician.Maintain minutes of meetings / files, as necessary.Return incomplete records / charts to nursing service for correction.Answer telephone inquiries concerning medical records functions.; prepare written correspondence, as necessary.Other special projects and duties, as assigned.Job Requirements :
High school diploma or GED required or equivalent related work experience ANDRegistered Health Information Technician (RHIT) Certification AND / ORCertified Nurse Assistant with current state license.One (1) to three (3) years related experience; supervisory experience preferred, as necessary.Practical knowledge of medical terminology and record keeping.Effective verbal and written English communication skills.Demonstrated basic to intermediate skills in Microsoft Word, Excel, Power Point and Outlook, Internet and Intranet navigation.Highest level of professionalism with the ability to maintain confidentiality.Ability to communicate at all levels of organization and work well within a team environment in support of company objectives.Customer service oriented with the ability to work well under pressure.Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.Strong analytical and problem solving skills.Ability to work with minimal supervision, take initiative and make independent decisions.Ability to deal with new tasks without the benefit of written procedures.Approachable, flexible and adaptable to change.Function independently, and have flexibility, personal integrity, and the ability to work effectively with employees and vendors.Physical and Sensory Requirements :
Moderate physical activity :Push, pull, move, and / or lift a minimum of fifty (50) pounds to a minimum height of three (3) feet and be able to push, pull, move, and / or carry such weight a minimum distance of fifty (50) feet.Reach overhead and push, pull, move, and / or lower a minimum of twenty (20) pounds.Climbing on a stool or ladder to a maximum of eight (8) feet.Standing and / or walking for more than four (4) hours per day.Bending and / or stooping for more than one (1) hour at a time.
