Experienced Medical Records LPN

Job Title: Medical Records Assistant, LPN Wage Level: Hourly

Department: Nursing Effective Date:

Reports To: Medical Records Director Review Date:

Safety Level: Safety Sensitive Position

General Purpose

Under the direction of the Director of Nursing, responsible for preparation of medical record upon

admission, maintenance of record and record closure at discharge.

Qualifications and Skills

• Must be a Licensed Practical Nurse or Certified Medication Technician in good standing and meet State and Federal licensure requirements
• Working knowledge in medical terminology, and physician orders
• Must have excellent telephone, communication and interpersonal skills
• Must possess good organizational and filing skills
• Capable of performing basic computer skills required for electronic documentation
• Possess working knowledge of computers, keyboard and data processing skills
• Must be capable of maintaining regular attendance
• Must have patience, tact, enthusiasm, and positive attitude toward the elderly and disabled
• Must be able to speak, read, write, and understand English
• Must be at least 18 years of age
• Must be capable of performing the ESSENTIAL JOB FUNCTIONS and PHYSICAL AND SENSORY REQUIREMENTS FOR ALL JOB FUNCTIONS as outlined below

Standard Requirements

• Support the Mission, Values, and Vision of Methodist Village Senior Living and the Campus
• Knowledgeable of resident rights and ensures an atmosphere, which allows for the privacy, dignity, and well-being of all residents in a safe, secure environment
• Report to Management immediately all instances of abuse, neglect, misappropriation/handling of resident property, or other concerns such as inadequate staffing, etc.
• Participate in all investigations as required
• Follows policies for acceptable attendance, uniform and dress codes including personal hygiene, and other work duties as assigned
• Support, cooperate with, and implement specific procedures and programs for:
• Safety, including standard precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs
• Maintain confidentiality of all data, including resident, employee, and operations data and comply with HIPAA Privacy and Security
• Comply with all Quality Assurance and regulatory requirements
• Comply with current law and policy to provide a work environment free from harassment, and all illegal and discriminatory behavior
• Complete required in-service training

• Support and participate in common teamwork and provide great customer service
• Cooperate and work together with all co-workers; treating fellow staff members like you want to be treated and avoid spreading rumors and gossip
• Plan and complete job duties with minimal supervisory direction, including appropriate judgment
• Use tactful, appropriate communications in sensitive and emotional situations
• Follow up as appropriate with supervisor, co-workers or residents regarding reported complaints, problems, and concerns
• Promote positive public relations with residents, family members, and guests

Essential Job Functions

Medical Record Functions-

• Enters resident information into computer system regarding new admissions
• Prepares records on new admissions ensuring all necessary forms are present
• Reviews records, MARS and TARS for accurate transcription and enters any changes into computer system
• Reduce records each month, files information in office files, and retrieves information from files when needed
• Compiles discharge records, closes records, and files information in office files
• Performs record audits for completeness ensuring all documents are present, in appropriate order, and that all necessary signatures are present and timely
• Ensures physician completes and signs discharge summaries
• Ensures physician completion of Medicare certification / recertification
• Review Pharmacy reports and corrects transcription errors
• Maintain and file discharge and reduced medical records in an orderly and appropriate manner
• Responsible for copying medical records due to records request based on corporate policies and procedures
• Maintain HIPAA Log
• Complete closed record audit at discharge
• Notifies Pharmacy of medication orders
• Maintain emergency computer outage log
• Maintain confidentiality of all resident care information

Committee Functions-

• Participate and attend daily clinical QA meetings, weekly and monthly subcommittee meetings
• Attend daily morning meeting as required
• Attend family council meetings/resident council meetings by invitation
• Serve on, attend and participate in various committees of the facility as appointed by the Administrator

Safety & Equipment Functions-

• Ensure that all personnel, residents and visitors follow established policies and procedures, including safety regulations, fire protection and prevention policies, smoking regulations, infection control procedures, and waste and disposal procedures
• Be familiar with, and use as appropriate, all items of personal protective equipment offered by the facility, including, but not limited to, masks, gowns, gloves, and back brace to be worn when lifting
• Wear and/or use safety equipment and supplies (e.g. back brace, mechanical lifts, etc.) when moving or lifting residents
• Adhere to all safety policies and procedures
• Ensure and maintain clean and safe work environment for residents and staff including participation in safety QA program
• Review accident/incident reports and establish safety training and prevention programs

Other Job Functions-

• Communicates with staff, sponsors, residents, and visitors, and assists in solving problems as necessary
• Assists with new employee orientation as related to Medical Records
• Adheres to all facility and departmental policies and procedures
• Perform complete record audit quarterly and PRN
• Follow infection control standards
• Understands and ensures implementation of State and Federal Regulations
• Performs other duties related to admissions, discharge, Medical Records, and the coordination and distribution of supplies and assists with other nursing functions in emergency situations
• Performs as Charge Nurse (if licensed) as required
• Perform all other duties as assigned by supervisor

Working Conditions

• Interact with residents, family members, staff, visitors, government agencies / personnel, etc. under all conditions / circumstances
• May be subject to hostile and emotionally upset residents, family members, staff, visitors, etc., under all conditions / circumstances
• May be subject to frustrations in meeting work demands due to frequent interruptions
• May be exposed to infectious waste; diseases, conditions, etc., including exposure to the HIV and Hepatitis viruses, etc.
• May be exposed to tobacco smoke in designated smoking areas

Physical & Sensory Requirements For All Job Functions

• Ability to move throughout work environment
• Ability to lift, carry, push, pull, bend, reach, grasp, perform fine manipulations, etc., necessary to perform job duties
• Ability to remain calm under stress
• Ability to communicate with staff, residents, sponsors, visitors, and government/ personnel
• Ability to distinguish odors
• Capable of regular attendance
• Obtain annual TB skin test, if possible, and flu vaccination as required by State and Federal regulations

I understand this job description and its requirements. I understand that this is not an exclusive list of the job functions and that I am expected to complete all duties as assigned. I understand these job functions may be altered by management without notice. I understand that this job description in no way constitutes an employment agreement and that I am an at-will employee.

_________________________________ _________________________________

Employee Signature Date

_________________________________ _________________________________

Supervisor Signature Date

Job Type: Full-time

Pay: From $25.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Physical Setting:

• Long term care
• Nursing home

Work Location: In person

Salary : $25