Position Summary

The Medical Record Technician is trained to work throughout the record processing section of the department performing customer service duties, Prep/Scan/Index (PSI) of paper medical record documentation, deficiency analysis and birth certificate completion. Based on the job assignment, the technician will be responsible for:

1. Customer Service/PSI (Prep, Scan, and Index): process requests for medical records from walk-ins, fax, and phone requests. Process documents into the document imaging system within 24-48 hours of receipt, selecting the appropriate encounter and document type to ensure easy retrieval.
2. Quantitative analysis of medical records to ensure completeness of documentation as defined in the Medical Staff Rules and Regulations. Associate must identify deficiencies and link the deficiency to the responsible in the Electronic Medical Record (EMR).
3. Birth Certificate completion including paternity acknowledgement and fetal death reports when appropriate. Responsible for entering the legal name of the newborn into the electronic medical record system. Organizes fetal monitor strips for shipment to be digitized.

Associates are expected to assist in the evaluation of methods and participate in problem solving. Provide assistance to customers and hospital personnel. Associate must use a good sense of judgment and display responsibility with minimal supervision. Must organize work and set priorities; work as a team member with peers and other associates; communicate effectively with customers from all levels; withstand stress of a fast-paced environment; handle confidential material; easily adjust to changes in policies, procedures, schedule and fluctuation in workload; understand procedures of all computer applications used in Health Information Department; endure excessive sitting, moderate walking, standing, lifting, have finger dexterity and complete use of hands, arms, and feet. Must work weekends and holidays, as assigned. Performs other duties as assigned by Manager/Director. Must have good vision and good hearing acuity.

Minimum Requirements

Education

• High school graduate or equivalent.

Experience

• Minimum of one year experience in health information department or medical office. In lieu of experience, an Associate Degree in HIM.
• Electronic health record processing experience

License/Registration/Certifications

• Must be eligible to obtain and retain South Carolina Notary Status

Preferred Requirements

Preferred Education

• Associates Degree HIM

Preferred Experience

• Working knowledge of standards and legal requirements for acute care medical records

Preferred License/Registration/Certifications

• RHIT

Core Job Responsibilities

• Assist with the training of new employees to accomplish departmental goals.
• Assures that work is performed according to established procedures
• Monitors workflow and keeps backlogs to a minimum.
• Communicates clearly and effectively both orally and in writing.
• Maintains patient confidentiality by not revealing and/or discussing patient information with anyone who does not have a legitimate interest in the information.
• Monitors faxing and printing of patient records to ensure legitimacy and accuracy.
• Answers telephone using proper phone etiquette receiving and relaying messages and imparting authorized information to authorized recipients.
• Works as a team member with Management and other departments.
• Provides assistance to co-workers to ensure accuracy and uniformity in procedures.

Customer Service/PSI Technician

• Process Customer Service (Walk-in, fax, and phone requests)
• Enters incoming requests for medical information into the correspondence tracking system within 24 hours of receipt 95 percent of the time.
• Prepares all documents for scanning by removing staples, paper clips, sticky notes, COLD documentation and rubber bands – 1000/hour.
• Photocopies all damaged documents so that they can go through the scanning process.
• Scans all documents through the scanner into the Optical Imaging System.
• Assigns appropriate batch names in DCS/QCI to ensure proper identification of documents for quality control review.
• Cleans scanner on daily basis.
• Correctly reviews and indexes batches of documents scanned into the imaging system: reviewing all pages and verifying patient name, dates of service, CNS number, etc.
• Assigns document identification and index all forms to the correct encounter number and re-scan forms, as needed for clarity and accuracy.
• Searches for and indexes batches in the error queue on a daily basis.
• Other duties as assigned

Analysis Technician

• Process Customer Service (Walk-in, fax, and phone requests)
• Enter new dictators into transcription system database.
• Stays informed of regulatory requirements and Medical Staff Rules and Regulations requirements for chart completion.
• Quantitatively analyzes inpatient medical records for completeness according to department schedule through the EMR – 100 inpatient charts per day.
• Reviews all EMR systems prior to assigning deficiencies.
• Aids physicians in completion of their medical records by answering questions concerning deficiencies.
• Monitors all deficiency work lists in EMR ensuring assignments are processed.
• Reassigns declined deficiencies within three days.
• Processes unlinked signature deficiencies on a daily basis.
• Assist with PSI batch processing (Look up/create scanned encounters and prep/scan/index).
• Assist with Release of Information request logging.
• Other duties as assigned

Birth Certificate Tech

• Maintains awareness of changes in the Vital Statistics Registration System

• Interviews birth mother and performs record review to obtain data for the birth certificate/fetal death report.
• Files original birth certificates, paternity acknowledgment and/or fetal death reports with the County Registrar within five days after delivery.
• Enters data in Vital Records (WebBirth) system with 99% accuracy.
• Enters baby’s full name in Electronic Medical Record (EMR) the first business day after discharge.
• Retrieves discharged patient records from the nursing units and the Emergency Center.
• Review, complete, and submit Vital Record follow up reports as received within 24 hours of receipt the next weekday.
• Retrieves fetal monitor strips, microfiche and film as requested.
• Correctly files fetal monitor strips, microfiche and film back when returned.
• Log, box and submit fetal monitor strips for off-site processing.
• Assist with PSI batch processing (Look up/create scanned encounters and prep/scan/index).
• Assist with Release of Information request logging.
• Assist with Customer Service (Walk-in, fax, and phone requests)
• Other duties as assigned