SUMMARY

Responsible and accountable for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long-term care facilities.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

§Prepares charts for new admissions.

§Closes medical records upon discharge.

·Develops schedule for and conducts audits of the clinical and electronic health records.

·Monitors physician visit schedule.

·Maintains master index system.

·Orders, maintains, and distributes medical records forms.

·Monitors procedures to maintain confidentiality of patient information and guard against loss or destruction of data in accordance with the facility’s policy and procedures.

·Maintains records and completes required forms and documents in accordance with facility policies and state and/or federal regulations.

ENTRY QUALIFICATIONS

·High school diploma or equivalent.

·Working knowledge of medical terminology.

·Proficient in the use of personal computer.

SUPERVISORY RESPONSIBILITIES

Supervises Medical Record assistant, if any, and others for whom they are administratively or professionally responsible.