What are the responsibilities and job description for the Central Supply/ Medical Records position at Wilshire at Lakewood Care Center?
Wilshire Lakewood Care Center Rehab & Healthcare strives for excellence!
Central Supply/ Medical Records Reports To: Director of Nursing
Supervisers: Position requires no supervision of other staff members.
Central Supply/ Medical Records Requirements:
- Must have at a minimum a high school diploma or the equivalent.
- Must have at a minimum a limited ability to use computers.
- Must have understanding of chart and filing organizational systems.
Medical Records Duties:
- Maintain nursing/medical records mail log.
- Maintain record of admits and discharges
- Prepare new charts for incoming residents
- Place ICD-10 codes and diagnoses on facesheet and cumulative diagnoses sheet
- Close out charts for discharged residents
- Maintain an organized filing system for resident records
- Ensure that doctors have signed all necessary forms in chart including P.O. forms –this will require both mailing of the documents and communication with the doctors periodically
- Ensure that doctors perform annual physicals for each resident
- Audit each chart within 2 weeks of a new admit for necessary initial assessments (social services, dietary, activities, nursing)
- Audit each chart periodically for necessary documents including nurse’s notes, monthly summaries, weights and vital signs, doctor progress notes and physicals
- Thin charts every three months and/or at discharge
- File medical records in resident charts
o Telephone Orders
o MDS Records/Careplans
- Maintain stock of nursing forms at nurse’s station for use by staff.
- Assist in keeping nurses station clean and organized.
- Assist in responding to phone calls and family/resident concerns.
- Maintain nurses station fax machine including the replacement of ink cartridges and adding paper.
- Participate in quality assurance functions including but not limited to:
o Acting as secretary to the quality assurance committee including but not limited to keeping minutes, scheduling meetings, and sending meeting notices.
- All other duties as assigned by supervisor.
