Medical Records

Primary Responsibilities

The Medical Records Coordinator will maintain and update the residents’ clinical records in a confidential, systematic, well-organized manner in conjunction with acceptable policies/procedures that include OBRA guidelines; Texas State Standards and Individual Nursing Home Standards. The Medical Records Coordinator will report directly to the Director of Nursing.

Essential Functions

• File documents in the appropriate records daily.
• Enter new admits and discharged residents in the Admission/Discharge Log daily.
• Track outgoing telephone orders and other documents pertaining to the resident.
• Thin the residents’ active charts daily by the census.
• Maintain tracking log for Progress Notes, Physician’s History and Physical.
• Send out monthly compliance letters to physicians and follow up bi-monthly on progress of visits.
• Communicate with Administrator, DON and Medical Director on the compliance of the physicians’ services.
• Maintain the Death Report and mail/fax to the State each month no later than the 10th of the month.
• Print the MARS/TARS and Consolidated Orders.
• Maintain and update Master Signature Legend.
• Audit new admits, re-admits and discharged residents’ records and report findings during the morning meeting.
• Maintain HIPAA log of requests for releases of information received pertaining to past or present residents of the facility.
• Complete monthly QA forms and participate in the QA and compliance meetings as required.
• Follow up on incomplete records daily.
• Check Completion of Discharge Summary.
• Close out discharged residents’ records.
• Maintain the Destruction Log for closed records.
• Box previous year closed records for storage.
• Order nursing department office supplies/forms and maintain availability at nurses’ station.
• Update forms in various locations as changes are made by the corporate Forms/Policy Committee.
• May be necessary to assist in the evacuation of residents during emergency situations.
• Actively assist and participate in the enhancement of the lives of our residents through our dedicated approach to patient care and our census-building program.
• Actively assist and participate in the development and retention of staff through; recruitment, training and nurturing the employees of the nursing home.
• Perform other duties and tasks as assigned by the Administrator or Director of Nursing in accordance to the qualifications and training

Educational/Training Requirements

• High school diploma or equivalent is required

Licensing Requirements

• None

Experience Requirements

• None

Physical Demands

The physical demands described here are representative but not necessary all inclusive, of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to effectively communicate. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.