Medical Records

The Medical Records Technician is responsible for maintaining and managing medical records in a healthcare, long-term care, or assisted living facility. This role involves ensuring that all medical records are accurately documented, securely stored, and easily accessible to authorized personnel. The Medical Records Technician also ensures compliance with healthcare regulations, including HIPAA, and supports the smooth operation of the medical records department by organizing, updating, and retrieving medical documentation as needed.

Key Responsibilities:

• Medical Records Management:

  • Organize, maintain, and manage patient medical records, ensuring all documentation is accurate, up-to-date, and complete.
  • Ensure that medical records are properly filed and securely stored, in compliance with facility policies and healthcare regulations, including HIPAA.
  • Retrieve and provide access to medical records for authorized personnel, ensuring timely responses to requests for patient information.
  • Process requests for medical records from patients, healthcare providers, and external agencies, ensuring all necessary documentation is provided.

• Documentation and Data Entry:

  • Accurately enter and update patient data into electronic health record (EHR) systems, including demographic information, treatment history, diagnoses, and medications.
  • Review medical documentation for accuracy, completeness, and adherence to facility standards.
  • Ensure that all required forms, consents, and legal documents are included in each patients medical record.

• Compliance and Confidentiality:

  • Ensure compliance with federal, state, and facility regulations regarding medical recordkeeping, including HIPAA and other privacy regulations.
  • Protect patient confidentiality by safeguarding medical records and ensuring that access is limited to authorized personnel only.
  • Conduct regular audits of medical records to ensure compliance with regulatory standards and identify areas for improvement.

• Record Retrieval and Distribution:

  • Assist healthcare providers by retrieving medical records and providing them with accurate patient information as needed for treatment, billing, or legal purposes.
  • Respond to requests for medical records from outside agencies, legal representatives, or patients, ensuring that all requests comply with facility policies and regulatory guidelines.
  • Prepare and deliver medical records for regulatory audits, inspections, and surveys as required.

• Quality Assurance:

  • Monitor the quality and accuracy of medical records, ensuring that all documentation is legible, complete, and correctly filed.
  • Participate in quality improvement initiatives to enhance the accuracy, organization, and accessibility of medical records.
  • Work with healthcare providers to ensure timely and accurate completion of medical documentation.

• Collaboration and Communication:

  • Work closely with healthcare providers, nursing staff, billing departments, and administrative personnel to ensure the efficient management of medical records.
  • Communicate effectively with patients and external entities regarding requests for records, confidentiality concerns, and other related issues.
  • Collaborate with other departments to address any discrepancies or issues related to patient records.

• Education: High school diploma or equivalent required. Certification as a Registered Health Information Technician (RHIT) or similar credential is preferred.
• Experience: Minimum of 1-2 years of experience in medical records management or a related role in healthcare is preferred.
• Skills:
  • Strong attention to detail and organizational skills.
  • Knowledge of healthcare regulations, including HIPAA and medical recordkeeping standards.
  • Proficiency with electronic health record (EHR) systems and medical terminology.
  • Ability to handle sensitive and confidential information with discretion.
  • Good communication skills and ability to work independently and as part of a team.

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