What are the responsibilities and job description for the Medical Records position at Selectis Health?
Selectis Health -
Medical Records / Central Supply
General Purpose :
Maintain residents' medical records in accordance with facility policies and with state and federal regulations. Administer the distribution and inventory of resident care supplies in accordance with facility policies and procedures.
Essential Job Functions
This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents. Therefore, the following list of duties is not all-inclusive :
Protect the security of medical records to ensure that confidentiality is maintained.
Release information to persons and agencies according to regulations.
Organize and maintain facility medical records system in compliance with corporate, state and federal regulations.
Code and quantify records from admission to discharge.
Maintain a documented, organized system, which is readily accessible by other authorized professionals.
Insure that all reports are completed within established time frames.
Maintain the resident census on a daily basis.
Maintain a current list of each physician's residents and send to the physician quarterly.
Pull charts for physicians' rounds each week and insure that documentation is present.
Monitor Restraint and Bowel & Bladder Programs to insure documentation is present.
Audit MAR and Treatment Sheets weekly.
Audit Narcotic count sheets weekly.
Perform chart audits as follows :
Admission audit - 24 hours after admission
Weekly audit of physician visits, progress notes, and nursing notes to insure that all signatures and dates are present.
Monthly audit of progress notes for all departments, monthly summaries, history & physical, etc., to insure that all forms are present and completed.
Discharge audit - Chart is to be complete within 72 hours including discharge summary and arrangement in
chronological order in each section of the chart so that material can be retrieved in an efficient manner.
File lab and x-ray reports on charts daily.
Review physician orders (including telephone orders) and monitor to be sure that lab, x-ray, diagnostic tests, consultations, etc., have been scheduled and followed through.
Maintain log / roster to identify when care plan meetings are due.
Insure that MDS documentation is placed in resident's medical record and that documentation is complete. Insure that MDS quarterly review sheets are completed with each care planning conference.
Schedule care plan meetings.
Notify family & staff 30 days in advance of care plan meeting, 15 days in advance and one week in advance.
Obtain interdisciplinary and physician signatures on final care plan.
Obtain the following information for admission of a new resident : History & Physical, Admit orders, Physician's Statement (Part of PAE), TB skin test and / or chest x-ray.
Maintain resident admission register and discharge list.
Insure that an Admission Identification Summary is completed for each resident admitted to the facility. Make copies of the form and distribute to the authorized personnel involved in resident care.
Maintain a list of residents hospitalized and dates of hospitalizations. Update individual hospitalization lists in charts.
Maintain a current list of diagnosis in each resident's medical chart.
Maintain a master index of all residents including length of stay.
Thin charts according to facility policies and arrange overflow in discharge chart order.
Maintain adequate stock of medical forms and documentation supplies.
Coordinate discharge and death records.
Collect medical records upon discharge or death, assemble them in proper order, and check for completeness. Incomplete charts are returned for proper correction or completion to nursing service or attending physician.
Maintain minutes of meetings / files as necessary.
Return incomplete records / charts to nursing service for correction.
Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
Attend in-service education programs in order to meet facility educational requirements.
Be familiar with Standard Precautions, Exposure Control Plan, Fire Drill & Evacuation Procedures and know how to use the information.
Protect residents from neglect, mistreatment, and abuse.
Protect the personal property of the residents of the facility.
Others as directed by the supervisor or administrator.
Inventory and stock supplies maintained at nurses' station in supply points, distribute appropriate supplies; record inventory and cost data and provide data to the business office and / or input into the computer.
Maintain a safe and orderly work area
Inventory and monitor central supply levels
Work with management to analyze supply usage and determine target inventory level and reorder points.
Order, receive, and restock in accordance with procedures.
Secure emergency or critical items.
Review crash cart daily and restock with each use.
Monitor cost and maintain related records.
Assist with Nursing Department activities to include administrative support; assisting residents, families, and visitors, and running errands to include travel to supply sources.
Attend in-service education programs in order to meet facility educational requirements.
Be familiar with Standard Precautions, Exposure Control Plan, Fire Drill & Evacuation Procedures and know how to use the information.
Maintain confidentiality of resident and facility records / information.
Protect residents from neglect, mistreatment, and abuse.
Protect the personal property of the residents of the facility.
Others as directed by the supervisor or administrator.
Minimum Qualifications
Medical Records certification preferred.
Practical knowledge of medical terminology and record keeping.
Organized and detailed in work performance.
Good communication skills with excellent self-discipline and patience.
Genuine caring for and interest in elderly and disabled people in a nursing facility.
Comply with the Residents' Rights and Facility Policies and Procedures.
Perform work tasks within the physical demand requirements as outlined below.
Perform Essential Duties as outlined above.
Working Conditions
Subject to frustrations in meeting work demands due to frequent interruptions.
Fast paced, required to make decisions quickly
Involved with residents, personnel, visitors, government agencies / personnel, etc., under all conditions and circumstances.
May work beyond normal duty hours, on weekends, and in other positions temporarily, when necessary.
Subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
May be subject to the handling of and exposure to hazardous chemicals
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