Health Information Services Technician

Position Summary:Supports the medical records department through a variety of clerical, technical and related support services that may be include:

• Assembles discharged charts, in discharge date order, in specified chart order.
• Places chart in appropriate numbered folder.
• Analyzes chart content for specified missing forms and/or content and signatures.
• Accurately assigns the incomplete chart to the appropriate practitioner or discipline in the computer system.
• Collects and manages the distribution of data, per policy
• Re-analyzes charts after the practitioners or disciplines have worked on charts.
• Accurately updates or clears the incomplete charts in the computer system.
• Performs coding in case of absence of HID Director.
• Reports significant events to the Director of HID for immediate follow-up.
• Completes dictation functions.

Essential Functions:

• Assembles discharged charts, in discharge date order, in specified chart order. Places chart in appropriate numbered folder.
• Adds diagnosis codes in Psych Consult and prints a face sheet.
• Analyzes chart content for specified missing forms and/or content and signatures.
• Reports significant events to the Director of HID follow-up
• Accurately assigns the incomplete chart to the appropriate practitioner or discipline in the computer system.
• Completes both of the above within 3 business days following discharge.
• Adds NRI data to ORYX if HID Director is not available.
• Re-analyzes charts after the practitioners or disciplines have worked on charts. Accurately updates or clears the incomplete charts in the computer system.
• Opens mail daily. Date stamps and adds medical record number to each piece of correspondence requesting release.
• Reviews each request for information and verifies authorization is valid. Processes each request as appropriate within 8 business days. Refers unusual request or questions to the Director of HID or Administration as appropriate..
• Processes subpoenas and court orders, including letters, follow-up, etc., according to procedure.
• Daily fax referral releases to the appropriate patient follow-up agency person. On the authorization indicate information and date faxed.
• Assists the HID Director and responsible for departmental functions in their absence
• In Scribe Doc performs transcription each day as appropriate; sending progress notes to appropriate units and UR.
• Filing of loose documents in discharged charts and permanent file.
• Scans chart as appropriate after completion.
• Assists with duties assigned i.e., Billing, Clinical Pertinence, Peer Review, etc.
• Maintains medical forms and copies.
• Participates in all educational and developmental activities as assigned; and seeks additional educational opportunities. Attends meetings as assigned
• Uses the medical record computer system to look up patient medical record numbers, print physician incomplete list, locate charts, etc.
• Pulls charts as requested and re-files charts accurately.
• Maintains HIPAA confidentiality rules in all daily activities.
• Other duties, as assigned, by the director

Minimum Qualifications:

Education: High School graduate or GED required.

Experience: Minimum of one (1) year prior work in a medical records department of a hospital of doctor’s office setting. Experience in a psychiatric setting preferred.

Age – specific Competencies: N/A

Licensure/Certification: N/A

Other Required Knowledge/Skills/Abilities: Must be able to operate desktop computer for data entry and record management. Must exercise sound judgment and decision making skills. Must be able to utilize general clerical skills when performing tasks. Must be able to prioritize work tasks and exercise time management skills. Knowledge of Medical Terminology; Knowledge of DSM V

HIPAA: Has access to secure patient/resident documentation ensuring confidentiality is met.

Work Demands/Environment:

Ability to stoop, kneel, crouch, reach, push, pull and lift; ability to finger (e.g. pick, pinch, type) and grasp; ability to express and exchange ideas by spoken word in an accurate, audible, and occasionally quick manner. Ability to perceive sound with or without correction and to make fine discriminations in sound. Ability to perform substantially repetitive motions of the wrist, hands, and fingers. Ability to perform substantially sedentary work, exerting between 10 to 20 pounds of force. Ability to lift or move objects. The worker is subject to some temperature changes but is largely protected from changing weather conditions.