Overview

Medical Records Assistant Primary Responsibilities

The primary purpose of this position is to assist the Medical Records Coordinator with the clinical records program according to the accepted record-keeping practices of the facility in compliance with state and federal regulations.

Responsibilities

Medical Records Assistant Essential Functions

• Assisting with the maintenance, organization and protection of the facility medical records. This includes:
  • Assisting with the monitoring of records for completeness, accuracy, timeliness and internal consistency while the resident is in the facility.
  • Assuring that all medical record information is protected, kept confidential and from loss or destruction.
  • Assisting with the audit of records of new admissions, in-house residents and discharge residents according to established time frames, using proper forms and establishing method of follow-up.
  • Assisting with audits as assigned by the facility staff and using established method of follow-up.
  • Labeling charts with pertinent information such as allergies, code status, resident’s name, physician’s name, etc.
  • Maintaining active records routinely and in proper order assuring accessibility as directed.
  • Maintaining admission packets and records as needed to initiate all required forms as directed.
  • Mailing forms to physicians for completion as directed.
  • Assisting with and controlling release of information requests to authorized persons per state and federal regulations and laws.
  • Assembling discharge records as directed.
  • Preparing discharge records for off-site storage and/or destruction according to facility guidelines, maintaining required time frames as directed.
  • Typing minutes of meetings/file as necessary.
  • Assisting with unit schedules pertaining to charting schedules, weight schedules, mantoux and physician visits.
  • Assisting with a manual resident index, a chronological discharge log and disease index.
  • Maintaining the confidentiality of all residents and their care to ensure resident rights, privacy and property are protected at all times.
  • Reporting and documenting resident and/or visitor incidents, accidents, complaints or allegations according to the facility’s policy and procedure using the designated occurrence reporting system.
• Complying with safety requirements, infection control measures, and maintaining a clean work environment in accordance with facility policy as indicated by:
  • Ensuring that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of work day, etc.
  • Abiding by all emergency protocols for crash carts, resident codes, fire safety, missing residents, tornado preparation, violent residents, Wander guard alarms, door alarms, and other facility policies as assigned.
  • Reporting any forms of abuse witnessed and aware of and taking appropriate action according to policy.
  • Following infection control and universal precautions procedures.
  • Following periodic cleaning schedules for equipment and returning equipment to proper area after use.
  • Ensuring the facility is maintained in a clean and sanitary manner at all times.
• Performing other duties as assigned by the Medical Records Coordinator, Director of Clinical Services, and Health Facility Administrator.

Qualifications

Medical Records Assistant Qualifications

• Must possess specific educational and experience requirements such as:
  • A high school diploma or GED.
• Have a thorough understanding of the principles of best medical record practices.
• Must possess managerial and interpersonal skills such as:
  • The ability to follow written and verbal instructions, function independently and make independent decisions when circumstances warrant such action.
  • Personal integrity and the ability to deal tactfully with residents, family members, visitors, government agencies and personnel.
  • The ability to work harmoniously with professional and non-professional personnel.
  • Judgment in prioritizing the performance of tasks, duties and responsibilities in accordance with established standards, policies and procedures.
  • The ability to be discrete and protect the integrity of confidential information and stay within Corporate Compliance and HIPAA.
  • Patience, a cheerful disposition, enthusiasm and a willingness to handle residents based on whatever maturity and physical level in which they are currently functioning.
  • The ability to adhere to professional code of ethics.
  • The ability to relate information concerning a resident’s condition to the appropriate staff members.
  • Knowledge on the use of personal computers, e-mail accounts, software programs such as Word and Excel and minor office machines such as faxes and copiers.
  • The ability to work Monday-Friday during normal business hours and the ability to take call and come in during off shifts as needed (i.e. weekends, midnights, and holidays).
• Desired qualifications include:
  • Two (2) years of experience in health care administration.