What are the responsibilities and job description for the Medical Records Staff position at Stillwater Post-Acute?
JOB DESCRIPTION
Medical Records Clerk
Department: Administration
FLSA Classification: Non-Exempt
Reports to: Director of Medical Records
Overview of the Position:
The Medical Records Clerk is charged with maintaining medical records in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained.
Miscellaneous Information:
Information explaining the Essential Functions, Safety Factors, and the Competency Evaluation columns, as well as the Risk Exposure Category legend is provided in the “Job Position Analysis Information” section located on the last page of this job description. (Note: The number assigned to each individual column corresponds to that same number in the “Analysis” section.)
Duties and Responsibilities
Administrative Functions:
- Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.
- Assist in organizing, planning and directing the medical records section in accordance with established policies and procedures.
- Assist in the orientation program for all personnel in accordance with our policies and procedures.
- Assist the Medical Records consultant as required.
- Maintain minutes of meetings/files as necessary.
- Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
- Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
- Collect, assemble, check, and file residents charts and personnel records as required.
- Ensure that schedules are followed as outlined for respective shifts/areas.
- Ensure incomplete records/charts are returned to nursing service for correction.
- Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing
- Follow established policies and procedures for the medical records section.
- Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
- Maintain a record of authorized information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
- Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
- Index medical records as directed by the medical records consultant.
- Maintain various registries as directed including register for admission and discharge of residents.
- Type reports for physicians as necessary.
- Collect charts, assemble them in proper order, and inspect them for competition.
- Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
- Assist in admission, transfer and discharge procedures as necessary.
- Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
- Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.).
- Assure that medical records taken from the department are signed in upon return to the department.
- File active and inactive records in accordance with established policies.
- Index medical records as directed.
- Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Clerk.
- Other related duties and responsibilities that may become necessary or appropriate to meet the administrative
- Needs of this facility.
Committee Functions:
- Perform secretarial duties for the committee of the facility as directed. Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.
Staff Development:
- Attend and participate in in-service educational classes and on-the-job training programs including annual OSHA and CDC in-service training programs concerning hazard communication, TB management, and bloodborne pathogens. Attend and participate in workshops, seminars, etc., as approved.
Safety and Sanitation:
- Report all unsafe/hazardous conditions, effective equipment, etc., to your supervisor immediately.
Equipment and Supply Functions:
- Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
- Ensure supplies have been replenished in work areas as necessary.
- Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of work day, etc.
Residents Rights:
- Maintain confidentiality of all pertinent resident care information to assure residents rights are protected.
- Knock before entering a resident’s room.
- Ensure that resident’s rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are followed.
Working Conditions:
- Works in office areas as well as throughout the facility and its premises.
- Moves intermittently during working hours.
- In subject to frequent interruptions.
- In subject to hostile and emotionally upset residents, family members, visitors, etc.
- Works beyond normal working hours, week-ends and holidays, and on other shifts as necessary.
- In subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
- Attend and participate in continuing educational programs.
- Communicates with nursing, and other department personnel.
- In subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well as reactions from dust, disinfectants, tobacco smoke, and air contaminants.
- In subject to pressure from multiple/emergency calls.
- In subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
- May be subject to the handling of and exposure to hazardous chemicals.
Educational Requirements:
- Must possess, as a minimum, a high school diploma.
Experience:
- Must be able to type a minimum of 35 words per minute, use dictation equipment, and have a working knowledge of medical terminology.
- On-the-job training provided in medical records procedures.
Specific Requirements:
- Must be able to read, speak, and understand the English language.
- Must possess the ability to make independent decisions when circumstances warrant such action and to remain calm during emergency situations.
- Must possess the ability to deal tactfully with personnel, residents, family members, visitors, and the general public.
- Must be knowledgeable of medical terminology.
- Must possess the ability to work harmoniously with other personnel.
- Must possess the ability to minimize waste supplies, misuse of equipment, etc.
- Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices.
- Must be able to follow written and oral instructions.
- Be knowledgeable in micro-computers, data input and output.
- Must not pose a direct threat to the health or safety of the individual in the workplace.
Physical and Sensory Requirements (with or without the Aid of Mechanical Devices)
- Must be able to move intermittently throughout the work day.
- Must be able to speak and write English language in an understandable manner.
- Must be able to cope with the mental and emotional stress of the position.
- Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
- Must meet the general health requirements set forth by the policies of this facility which include a medical and personal examination.
- Must function undependably, have flexibility, personal integrity, and the ability to work effectively with other personnel.
- Must have pleasant speaking voice.
- Must be able to push, pull, move, and/or lift a minimum of 25 pounds to minimum height of 3 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 10 feet.
- May be necessary to assist in the evacuation of residents during emergency situations.
