The position maintains the medical records of the center in accordance with policies and procedures established for the medical record keeping practices.

RESPONSIBLE TO: Medical Records/Health Information Coordinator

QUALIFICATIONS:

• Ability to establish procedures and to suggest changes for smoother operation.
• Be able to type and understand the Medical Record Systems, including filing. Understand and utilize medical terminology, ICD-10-CM, coding principles, concurrent and Discharge Analysis Procedures, medical legal aspects and possess management skills for a nursing home.
• Possess personal attributes to include professionalism, neatness, accuracy, articulates pleasantly and cooperative with all staff.

Education Background as follows:

MEDICAL RECORD ASSISTANT:

1. High school graduate or equivalent.
2. Minimum of 3 – 5 years of management or supervision in the field of medical records, preferably in nursing home setting.

PHYSICAL DEMANDS:

• Ability to read, write, hear and communicate adequately to complete job duties and responsibilities.
• Ability to move throughout center without assistance.
• Must be able to see adequately enough to read hand written medical records.

DUTIES AND RESPONSIBILITIES:

Are determined by the center and may include, but are not limited to the following:

• Determine upon admission of patients whether additional transfer data is needed and obtain missing information.
• Make sure that patient’s has an patient armband, in addition to the other required information.
• Check medical records quantitatively on admission and periodically (once per month minimum) to assure completeness, accuracy and internal consistency.
• Communicate with and assist the medical staff and allied health personnel in updating the records. Interact with other departments, physicians, administrator and regional support staff.
• Maintain flow of reports to the medical records.
• Upon discharge, check records quantitatively to assure completeness and accuracy within thirty (30) days of the discharge or in accordance with state requirements.
• Ensure that diagnoses have been listed according to ICD-10-CM and that abbreviated diagnoses are not recorded on the Admission-Summary sheet.
• Collect, collate and maintain statistical data as needed.
• Provide information to Utilization Review Committee, Quality Assurance Committee, medical audits and others as needed or instructed by the administrator.
• Maintain the numerical and unit numbering filing system for record identification.
• Maintain sign-out and follow-up controls of records.
• Maintain and control the release of information to authorized personnel.
• Type and/or transcribe reports or correspondence according to the needs of the Medical Records department.
• Attend meetings as required by the administrator.
• Be able to orient new employees to the procedure of the Medical Records department.
• Credentialed individuals may assist as preceptors to local students of an RHIT/RHIA program.
• Participate in development of and responsible for compliance with the budget of the Medical Records department.

Other duties as may be assigned from time to time