Medical Records

• Creating a culture that promotes teamwork and collaboration
• Listening attentively and courteously
• Honoring the uniqueness and worth of each individual
• Extending a warm and welcoming atmosphere
• Embracing new ideas, being flexible, and open to change

• Taking initiative and anticipating the needs of others
• Contributing our time and talents responsibly
• Using material, energy, and monetary resources as efficiently as possible
• Being predictive in problem solving

• Creating a daily practice of doing the right things.
• Being accountable for and being engaged in the commitments we have made
• Building trustworthy relationships with others
• Telling the truth
• Striving for quality and excellence in all we do

• Cherishing and promoting the worth of all human life
• Valuing the dignity of all work
• Promoting participation of team members in decision making
• Responding timely in communications

• Embracing creativity and new ideas
• Learning and growing from our mistakes
• Encouraging joy and laughter
• Taking the work, but not ourselves too seriously
• Having fun at work!

KEY POSITION SPECIFIC ROLES & RESPONSIBILITIES

• Oversees resident’s medical records; collects information from nursing staff, physicians and other sources and updates records and closes charts when necessary.
• Assembles, organizes, enters, maintains and audits information on resident’s chart and automated resident’s clinical record database and reports from database as needed to support information needs of the health care team; and maintains standardized resident cumulative diagnostic records on the nursing unit.
• Monitors and audits for completeness and accuracy in accordance with facility policy and regulations, and provides information to other departments as requested.
• Processes transfer or discharge records and maintains appropriate records on former residents
• Oversees that physician’s orders, lab results and department reports are located in the medical record.
• Monitors for timely physician visits per state regulations and reports any deviations to the Director of Nursing
• Notifies appropriate nursing staff of reported resident condition and functional ability changes as needed, and relays information to appropriate departments when changes occur to a resident’s care, location or status.
• Answers telephones and routine visitor questions; referring messages, requests, and non-routine questions to the proper parties.
• Completes resident admissions and discharge documents as directed. To include transfer and LOA.
• Distributes paperwork to unit staff, doctors, outside agencies, or resident’s families to be signed, read, completed, and filed.
• Under licensed nursing staff direction, orders medical supplies and medications from appropriate vendors and pharmacies and stores materials as appropriately.
• Under licensed nursing staff direction, relays routine lab and physical results to doctors and makes outside appointments and arranges transportation for residents as needed.
• Assists in performing qualities and quantitative analysis of medical records content and documentation, including tracking insurance documentation and checking that accurate Prior Authorization/Vendor forms are in charts and admission records are current with billing.
• Arranges public –aid approved transportation for residents as directed
• Ability to work other hours as needed or required for resident care.
• Follow safety guidelines and trainings to prevent work injuries.
• Attends all mandatory in-services annually
• Adjusts to changes in shift assignments to meet resident and facility needs.
• Ability to perform other duties as directed by supervisor.