Medical Recrods Assistant

General Purpose

The primary purpose of your job position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our facility's established privacy policies and procedures.

Essential Duties

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 department in accordance with established policies and procedures.

• Assist the Medical Records/Health Information Consultant as required.

• Maintain minutes of meetings.

File 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.

• Retrieve resident records (manually/electronically).

Deliver as necessary.

• Files information such as nurses' notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.

• Collect, assemble, check and file resident charts as required.

• Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.

• Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.

• Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.

• Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized in our policies and procedures.

• Maintain a record of authorized information released 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.

in accordance with current Privacy Rules.

• Index medical records as directed by the medical records/health information consultant.

• Maintain various registries as directed including register for admission and discharge of residents.

• Transcribe and type reports for physicians as necessary.

• Collect charts, assemble them in proper order, and inspect them for completion.

• Pick up and deliver resident medical records from wards, nurses' stations, and other designated areas as necessary.

• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.

• 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.)

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