Job Summary :

The Health Information Management Resource Clerk is responsible for managing and securing medical records while working on the patient care units as assigned. This position is responsible for maintaining a complete and organized inpatient medical record. Responsible for filing all loose reports within the medical record. Assures there are printed chart forms available for providers. Maintains accurate census on unit and prints 20 copies at end of shift and places in assigned location. At discharge, breaks down medical record according to chart order. During shift may be required to assist with Emergency transfers calls and providing copy of medical record for such. Answer telephones as needed. Uses verbal, electronic and written communications techniques to maintain the operations of the assigned area.

Supervisory Responsibility:

None

Position Qualifications:

High School graduate or GED

Clerical/secretarial experience

Medical Records experience, preferred

Medical terminology, preferred

Key Responsibilities / Job Accountabilities:

• Maintains inpatient medical records, assuring they are current, complete and identified
• Assures all patient information is filed on medical record
• Monitors and assures H/P, Initial Psych Eval are printed and filed in the medical record within 24 hours of admission
• Tags for signatures on Physician Admission and Discharge Orders
• Assures the discharged chart is disassembled according to the HIM process, including removing all staples, all patient reports/documentation are labeled and assembled in order
• Assures patient labels are printed and in chart, as well as in the patient label notebook
• Assures every medical record has at least 5 blank progress notes and 5 physician orders
• Assures patient labels are on all medical record forms for Inpatients
• Prepares Admission packets (green folder)
• Prepares Discharge packets (manila envelope)
• Prints and fills documents drawer with forms daily (at least 5 copies of each, using the US shared drive)

• Performs other duties that maybe assigned by Nursing Supervisor, in an emergency situation

• Promotes a compassionate environment when communicating with team members, patients and families.

• Follows hospital and HIM policies and procedures as well as Joint Commission, and other governing agency regulations.
• Maintains safe and clean environment by complying with procedures, rules, and regulations,
• Adheres to infection-control policies and protocols.

Additional Skills / Qualifications:

• Ability to complete tasks with minimal supervision
• Good oral and written communication skills
• Ability to cope with stressful situations and adjust to varying workload requirements
• Interest in working with patients with psychiatric/behavioral health diagnoses
• Flexibility in work schedule
• Accurate spelling and transcription
• Telephone, pager system, nurse call systems
• Computer terminal data entry excel and word.
• Phone etiquette

CERTIFICATES, LICENSURES, REGISTRATIONS:

Valid and active driver’s license

ATTENDANCE:

Regular and punctual attendance.

LANGUAGE SKILLS:

English is the primary language of the facility. Ability to read and write, communicate clearly with coworkers and customers and to respond to appropriate questions regarding work process or work product.

MATHEMATICAL SKILLS:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions and decimals as appropriate to the position.

REASONING ABILITY:

Ability to apply common sense understanding to carry out instructions furnished in written, oral and/or diagram form. Ability to define and solve problems and collect data.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES :

To perform this job successfully, an individual must be able to perform each essential function satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to identify and implement components of the administrative process. Identify learning needs and teach patients and families. Ability to communicate and collaborate with a variety of teams and individuals. Working knowledge and ability to apply professional standards of practice in job situations.