What are the responsibilities and job description for the Medical Records Director position at Hyatt Family Facilities?
MEDICAL RECORDS
SUPERVISED BY: DIRECTOR OF NURSING
Job Summary:
Maintaining all electronic and paper records for the facility in accordance with Washington
State Guidelines. Medical Records reports to Director of Nursing and Administrator.
Standard Requirements
1. Support the Missions, Values, and Vision of Hyatt Family Facilities and the
facility.
2. Protect Residents Rights and ensure an atmosphere which allows for the privacy,
dignity and wellbeing of all residents in a safe, secure environment.
3. Support, coordinate with, and implement specific procedures and programs for:
A. Safety, including universal precautions and safe work practices,
established fire/safety/disaster plans, risk management and
security, report and/ or correcting unsafe working conditions,
equipment repair and maintenance needs.
B. Confidentiality of all data, including resident, employee and
operations data.
4. Support and participate in common teamwork:
A. Cooperates and work together with all-coworker; plan and
completes jib duties with minimal supervisory direction, including
appropriate judgment.
B. Uses tactful, appropriate communications in sensitive and
emotional situations.
C. Follows up as appropriate with supervisor, co-workers or
residents regarding reported complaints, reports, and concerns.
D. Promotes customer services with residents, family member and
guests
E. Adheres to requirements for in-service trainings; attendance, uniforms, department and dress code policies, including personal
hygiene, and completes other work duties as assigned.
Responsibilities and Duties:
1. Responsible for auditing and thinning all medical charts.
2. Closes and files discharged resident medical charts. Reviews charts of discharged
residents for the deficient information and ensures compliance for correction of
deficient documentation.
3. Files resident medical information in the resident chart in a chronological way.
Assures that each section of the residents record is maintained in a net, organized
and readable format.
4. Ensures that Physicians orders, telephone orders and other records requiring
signatures are received and filed within the required time frame.
5. Maintains effective communication with others, both inside and outside the
department, to give or obtain needed information
6. Ensures that all residents are seen by their physicians, and routine lab work is
completed and filed in the required time frames.
7. Assist in Medicare billing procedures.
8. Assures personal and staff compliance to all State and Federal regulations including
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
9. Assures personal and staff compliance to Residents Rights.
10. Works with and assists the Director of Nurses and Administrator as needed.
11. Develop and maintain a good working rapport with inter-department personnel as
well as other departments within the facility.
12. Perform miscellaneous duties and assists business office personnel as
required/directed.
13. Attend and participate in workshops, seminars, etc., as approved
14. Follows all submission procedures in accordance with CMS for MDS submissions.
15. Other related duties and responsibilities that may become necessary to assure that the needs of the facility are met.
16. Set up transportation for residents medical/social outing
17. Make appointment packets for residents medical appointments
18. Submit Yakima Transit Applications for new Admits
Physical demands of the job:
1. Frequent tasks involving walking throughout the shift. Distances typically less
than 200 feet with occasional walking greater distance, walking is on even
surfaces.
2. Occasional sitting during duties, the majority of which will be at the nurses
station.
3. Occasional standing does not need to be static.
4. Occasional squatting and/or bending, necessary mostly during medication pass
or residents assessment.
5. Lifting up to 10lbs. frequently, 11- to 25 lbs. occasionally, 26 to 50lbs seldom and
lifting greater than 50lbs. is not required.
6. Repetitive movements requires following proper body mechanics. Notify
supervisor of any concerns. Fine repetitive motor skills will be used frequently;
gross repetitive motor skills will be used occasionally.
7. Occasionally push/pull up to 25 pounds of force.
8. Occasional twisting, seldom climb or use of stairs; never crawl
9. Frequent reach from shoulder height to knees; seldom reach above shoulders or
below knees.
10. During the Covid-19 outbreak, N-95 masks are to be worn during the duration of
your shift.
11. When facility is not in an active outbreak staff are to wear surgical masks, KN[1]90/95s unless on observation to which N-95s are still mandated.
Facility Specific Duties and Responsibilities:
Troubleshoot problems as related to computers, computer components, internet, and internet functionality.
Conditions of Environment
1. Controlled temperature, primarily indoor, well lit, maintained flooring, smoke free
and occasional odors that dissipate. Noise level is maintained quiet to moderate.
2. Potential exposure of Covid-19 and mutated strains during the Pandemic.
Qualifications: Health care experience preferred.
1. Must be at least 18 years old.
2. Must have knowledge of computing systems, operating and troubleshooting
3. Be familiar with state and federal laws pertaining to Nursing Home guidelines for maintaining records
SUPERVISED BY: DIRECTOR OF NURSING
Job Summary:
Maintaining all electronic and paper records for the facility in accordance with Washington
State Guidelines. Medical Records reports to Director of Nursing and Administrator.
Standard Requirements
1. Support the Missions, Values, and Vision of Hyatt Family Facilities and the
facility.
2. Protect Residents Rights and ensure an atmosphere which allows for the privacy,
dignity and wellbeing of all residents in a safe, secure environment.
3. Support, coordinate with, and implement specific procedures and programs for:
A. Safety, including universal precautions and safe work practices,
established fire/safety/disaster plans, risk management and
security, report and/ or correcting unsafe working conditions,
equipment repair and maintenance needs.
B. Confidentiality of all data, including resident, employee and
operations data.
4. Support and participate in common teamwork:
A. Cooperates and work together with all-coworker; plan and
completes jib duties with minimal supervisory direction, including
appropriate judgment.
B. Uses tactful, appropriate communications in sensitive and
emotional situations.
C. Follows up as appropriate with supervisor, co-workers or
residents regarding reported complaints, reports, and concerns.
D. Promotes customer services with residents, family member and
guests
E. Adheres to requirements for in-service trainings; attendance, uniforms, department and dress code policies, including personal
hygiene, and completes other work duties as assigned.
Responsibilities and Duties:
1. Responsible for auditing and thinning all medical charts.
2. Closes and files discharged resident medical charts. Reviews charts of discharged
residents for the deficient information and ensures compliance for correction of
deficient documentation.
3. Files resident medical information in the resident chart in a chronological way.
Assures that each section of the residents record is maintained in a net, organized
and readable format.
4. Ensures that Physicians orders, telephone orders and other records requiring
signatures are received and filed within the required time frame.
5. Maintains effective communication with others, both inside and outside the
department, to give or obtain needed information
6. Ensures that all residents are seen by their physicians, and routine lab work is
completed and filed in the required time frames.
7. Assist in Medicare billing procedures.
8. Assures personal and staff compliance to all State and Federal regulations including
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
9. Assures personal and staff compliance to Residents Rights.
10. Works with and assists the Director of Nurses and Administrator as needed.
11. Develop and maintain a good working rapport with inter-department personnel as
well as other departments within the facility.
12. Perform miscellaneous duties and assists business office personnel as
required/directed.
13. Attend and participate in workshops, seminars, etc., as approved
14. Follows all submission procedures in accordance with CMS for MDS submissions.
15. Other related duties and responsibilities that may become necessary to assure that the needs of the facility are met.
16. Set up transportation for residents medical/social outing
17. Make appointment packets for residents medical appointments
18. Submit Yakima Transit Applications for new Admits
Physical demands of the job:
1. Frequent tasks involving walking throughout the shift. Distances typically less
than 200 feet with occasional walking greater distance, walking is on even
surfaces.
2. Occasional sitting during duties, the majority of which will be at the nurses
station.
3. Occasional standing does not need to be static.
4. Occasional squatting and/or bending, necessary mostly during medication pass
or residents assessment.
5. Lifting up to 10lbs. frequently, 11- to 25 lbs. occasionally, 26 to 50lbs seldom and
lifting greater than 50lbs. is not required.
6. Repetitive movements requires following proper body mechanics. Notify
supervisor of any concerns. Fine repetitive motor skills will be used frequently;
gross repetitive motor skills will be used occasionally.
7. Occasionally push/pull up to 25 pounds of force.
8. Occasional twisting, seldom climb or use of stairs; never crawl
9. Frequent reach from shoulder height to knees; seldom reach above shoulders or
below knees.
10. During the Covid-19 outbreak, N-95 masks are to be worn during the duration of
your shift.
11. When facility is not in an active outbreak staff are to wear surgical masks, KN[1]90/95s unless on observation to which N-95s are still mandated.
Facility Specific Duties and Responsibilities:
Troubleshoot problems as related to computers, computer components, internet, and internet functionality.
Conditions of Environment
1. Controlled temperature, primarily indoor, well lit, maintained flooring, smoke free
and occasional odors that dissipate. Noise level is maintained quiet to moderate.
2. Potential exposure of Covid-19 and mutated strains during the Pandemic.
Qualifications: Health care experience preferred.
1. Must be at least 18 years old.
2. Must have knowledge of computing systems, operating and troubleshooting
3. Be familiar with state and federal laws pertaining to Nursing Home guidelines for maintaining records
