Medical Records

The Medical Records Coordinator is responsible for the overall maintenance and good order of the Medical Record. Assures that the record is properly labeled, complete, organized, and controlled. Includes Release of Information, Patient Information Logs, Medicare Documentation, Death Reporting, & Confidentiality. May supervise one or more staff members. ESSENTIAL DUTIES & RESPONSIBILITIES GENERAL RESPONSIBILITIES • Assembles and packages admission items appropriately; ensures that H & P is on chart within 48 hours of admission. • For re-admissions: copies designated sections of previous chart and incorporates into current chart. Ensures that original DNR sheets are brought forward to new chart and copies are left in old chart. Ensures that copies of the MDS are made for re-admissions (15 months to chart as appropriate) • Requests discharge summaries from the hospital for all patients admitted as transfers from the hospital. • Ensures Medicare certification program activities. • Ensures that each patient has an annual physical exam. • Monitors and schedules physician visits. • Performs quality audits – specific to Medical Record Policy and the Company’s Quality Assessment & Assurance Program. • Receives thinned charts, places in chart order and checks for completeness. • Receives charts for discharge patients, places in order, analyzes and ensures completion. Timely and efficiently files non-electronic medical records into charts of discharged patients. • Maintains a control log for discharged records. Total records should reflect number of deficient that are within thirty (30) day window and those over thirty (30) days (delinquent). Reports number of deficiencies to Administrator monthly. JOB DESCRIPTION: Medical Records Coordinator 2 of 3 REVISED 10/02/2024 • Tracks incomplete charts and reports number of deficiencies on a monthly basis to Administrator. Total records should reflect number deficient that are within thirty (30) day window and those over thirty (30) days (delinquent). • Keeps basic statistical information, as assigned. • May be assigned by the Administrator as the credentials monitor. • Reports deaths on a monthly basis to the State Vital Statistics Office. • Acts as the release of information secretary for all record requests and initiates and coordinates the completion of Unusual Incident Report Packet requests for Medical Records. Notifies Administrator of all subpoenas. Maintains a log of all correspondence (record releases). • Provides input to staff at morning meetings concerning problem charting areas including layman’s terms on discharge instruction sheet, proper correction of charts, late entries, use of blue or black when making chart entries. • Communicates often with staff regarding problem areas. Keeps an ongoing list of problems and documents meetings with supervisor for progress made and plans of action taken. • Helps the Unit Secretary keep all duties timely, as needed. Substitutes for Unit Secretary during periods of vacation or illness. • Organizes and maintains filing system for deficient records, thinned records, and closed records. Maintains a master file for medical records forms. • Assures records and patient documentation is kept secure. Establishes a system for control and sign-out of medical records. • Initiates designated record destruction according to policy and ensures that certification documents are completed and filed in the destruction records tracking manual. • Keeps a master supply stock for medical records items. • Maintains confidentiality of all patient care information to assure patient rights are protected. • Reports all instances of abuse or neglect or other concerns to management. • Attends and participates in orientation, training, in-service education, and staff meetings. • Ensures all mandatory training is completed on time. • Performs other duties as necessary for the successful operation of the healthcare center. PREREQUISITES, SKILLS, & ABILITIES • One year of clerical experience in an office setting. Clinical office / medical record experience preferred. • Previous supervisory experience preferred. • Ability to communicate, comprehend, understand, and write messages. • Ability to follow directions. • Ability to type 40 words per minute. Proficient in Microsoft Word. • Excellent organizational skills. • Empathetic to the elderly and their needs. JOB DESCRIPTION: Medical Records Coordinator 3 of 3 REVISED 10/02/2024 • Good verbal and written communication skills. • Able to listen and work as a team player. • Ability to perform duties with minimal supervision