What are the responsibilities and job description for the Medical Records Director position at Inspire Behavioral Health?
Inspire Behavioral Health -
The position of Medical Records Director reports to the Administrator.
JOB DUTIES :
- Responsible for initiating, maintaining, and filing resident records in the facility.
- Maintain current policy and procedures for the medical records department.
- Monitor department budget as directed.
- Participate in the facility Quality Assurance and Assessment Committee.
- Maintain a quantitative / qualitative audit / monitoring process.
- Conduct comprehensive audits of charts on the following :
- Admission
- Advance Directives
- Bowel and Bladder Training
- Care Plans
- Clinical Overview
- Skilled Documentation
- Rehabilitation Documentation
- Weekly Summary
- Licensed Documentation
- Physician Orders
- Hospice
- Change in Condition
- Weekly and Monthly Weights
- Medication and Treatment Administration Records
- Flow Sheets
- Intake and Output Monitoring
- Discharge
- Perform focused reviews of problem areas. Trends and / or patterns, QA concerns, Quality Indicators, and survey issues.
- Maintain admission register and completed coding and indexing of admission diagnosis.
- Complete the chart closure process on all discharged resident charts.
- Complete the Monthly General Update Log.
- Complete the annual LTC-OSHPOD report.
- Complete the year-end census report.
- Maintain security of medical records.
- Maintain system for record filing, retention, and destruction.
- Process monthly recapitulation of physician orders.
- Other duties as assigned by the Administrator.
Qualifications :