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.
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