Medical Records Clerk

Medical Records Manager

DEPARTMENT: Medical Records

REPORTS TO: Administrator

WAGE: Non-Exempt

Maintain residents’ medical records in accordance with facility policies and with state and federal regulations.

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.
• 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.
• 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.
• 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.
• Prepare blank charts for admissions.
• File discharged charts, QA reports, minutes of meetings, consultant reports (all departments).
• 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.

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.
• 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

Physical and Sensory Requirements

• Assist in the evacuation of residents during emergency situations
• Meet general health requirements set forth by the policies of this facility, which may include a medical and physical examination.

Sitting

4 - 5 hours per 8 hour work shift. Alternates as needed to standing or walking.

Walking

1 - 2 hours per 8 hour work shift. Alternates to sitting on an occasional basis and to standing on a frequent basis.

Standing

2 - 3 hours per 8 hour work shift. Alternating to sitting on an occasional basis and to walking on a frequent basis

Key: Rarely = ≤ 5% Occasionally = 0% - 33%; Frequently = 33% - 66%; Constantly = 66% - 100%

*(Rarely – would most likely occur in emergency situations only)

Lifting:

WEIGHT

FREQUENCY

OBJECTS

1-10 lbs

Constantly

Paper and resident charts

11-20 lbs

Frequently

Paper and copy supplies

21-35 lbs

Occasionally

Paper and copy supplies

36-50 lbs

Occasionally

Paper and copy supplies

51-75 lbs

Occasionally

Paper and copy supplies

Carrying:

WEIGHT

FREQUENCY

OBJECTS

1-10 lbs

Constantly

Paper and resident charts

11-20 lbs

Frequently

Paper and copy supplies

21-35 lbs

Occasionally

Paper and copy supplies

36-50 lbs

Occasionally

Paper and copy supplies

51-75 lbs

Rarely

Paper and copy supplies

Bending: Occasionally

Squatting: Rarely

Kneeling: Rarely

Crawling: None

Climbing: None

Reaching: Occasionally

Grasping: Occasionally

Fine Manipulation: Frequently

Driving: Frequently

Numbers 1 through 3 indicate the risk potential of your exposure to blood or body fluids. Established procedures identify the appropriate personal protective equipment that you should use when performing tasks. The following numbers indicate your risk potential:

It is highly likely that while performing functions of this job, there will be tasks that will require you to be exposed to blood or body fluids.

This job does not normally involve contact with blood and/or body fluids but while performing the tasks associated with this job, it may be necessary for you to perform a task that involves exposure to blood or body fluids.

This job does not typically involve exposure to blood or bodily fluids. However, if the employee is trained in first aid/CPR, this may entail some exposure risk.

The position of Medical Records Manager has an exposure determination of .

EMPLOYMENT AT WILL: It is the express policy and intent of this facility that the employment relationship is one created and governed by the continuing will of both parties. I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause by either party, unless provided otherwise by a written agreement signed by the President of this company.

NONDISCRIMINATORY STATEMENT: This facility does not discriminate on the basis of race, religion, national origin, color, creed, sex, age, disability, marital or veteran status with regard to employment.

Job Description Review

I understand this job description and its requirements; and that I am expected to complete all duties as assigned. I understand the job functions may be altered from time to time. Management reserves the right to modify this job description at any time.

I further understand that the purpose of this job description is to identify the major duties and responsibilities of the job and that it is not intended to contain each and every duty inherent in this job.

I have noted below any accommodations that are required to enable me to perform these duties. I have also noted below any job responsibilities, which I am unable to perform, with or without accommodation.

Employee’s Signature Date

Supervisor or Orientation Leader Signature Date

Job Type: Full-time

Pay: $42,000.00 - $45,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Experience:

• Medical records: 1 year (Preferred)

Ability to Commute:

• Sevierville, TN 37862 (Required)

Ability to Relocate:

• Sevierville, TN 37862: Relocate before starting work (Required)

Work Location: In person

Salary : $42,000 - $45,000