Medical Records Assistant

POSITION DESCRIPTION:

Assists in developing and maintaining an appropriate health record service and system for the center.

QUALIFICATIONS

• High School diploma.

• Strong written and verbal skills in English necessary for business.

• Administrative and organizational ability.

• Knowledge of medical terminology.

• Previous experience in a skilled nursing home health care setting.

• Prior health record experience preferred.

• Basic computer experience preferred.

GENERAL DUTIES AND RESPONSIBILITIES:

ADMINISTRATIVE

• Maintains Health Record System according to Federal, State and Community requirements.

• Participates in assigned meetings and inservices.

TECHNICAL

• Initiates Resident Health Record.

• Initiates and maintains logs and indices as required:

• Admission/Discharge Register

• Master Patient Index

• Disease Index

• Medicare Log (if applicable)

• Audit System

• Discharge Control Log

• Chart Removal Log

• Resident Care Plan Log

• Telephone Audit Log

• Performs Audits

• Admissions

• Discharge

• Routine Quality Assurance Audits

• Special as required

• Coordinates Physician Documentation

• Telephone Orders

• History and Physicals

• Monthly Physicians Orders

• Physicians’ Progress Notes

• Certifications and Recertifications

• Discharge Summaries

• Thins charts and maintains overflow files as required.

• Records and maintains minutes of meetings as assigned.

• Inputs and prints computerized medical records forms.

• Prepares statistical reports as required.

• Destroys old health records as required.

• Assembles, analyzes and completes discharge records.

• Maintains unit filing system.

CONSUMER SERVICE

• Presents professional image to consumers through dress, behavior and speech.

• Adheres to Company standards for resolving consumer concerns.

• Ensures that all consumer/resident rights are protected.