PURPOSE OF POSITION:

To assist in maintaining medical records in accordance with Federal and State guidelines and in accordance with established policies and procedures.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Listed below is an outline of the major duties and responsibilities that will be required. Administrative authority, responsibility, and accountability necessary to perform the assigned duties under the supervision of the Health Information Management Manager are delegated to this position.

Every effort has been made to provide a position description that is as complete as possible. The duties outlined herein are not considered complete and final, and are not the only duties the technician will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position.

ESSENTIAL DUTIES & RESPONSIBILITIES

1. Does necessary filing, ie. patient documents, physician orders & other materials, to patient records in an accurate and timely manner.
2. Provides general clerical support as requested, including but not limited to faxing and making copies.
3. Assists in the transfer of SOC to hard binders.
4. Prints final care plans on all discharged patients.
5. Assists in the processing of DC’d patient charts and putting into discharge form.
6. Processes discharges monthly and transfers charts into boxes.
7. Assists in printing various reports for weekly IDT meetings.
8. Assists in providing copies of records for patient’s hospital admissions.
9. Assures that work/assignment areas are clean and records, files, etc., are properly stored before leaving on breaks, end of work day, etc.
10. Assists in assuring that charts/records do not leave the section except as authorized. Collect and return charts to their proper storage rack throughout the day.
11. As needed, assists with other duties including but not limited to:
12. Assisting Patient Records Auditor with following up on physician telephone orders.
13. Assisting in admission, transfer and discharge procedures as necessary.
14. Assisting with maintenance (per Policies & Procedures) discharged patient charts and performing basic audit (ie. signatures, legal forms, etc.).
15. Requesting medical records for all patient charts.
16. Printing final medications and care plans on all discharges patients
17. Picking up and dropping off orders to Dr. Guerra and Dr. Nduka
18. Printing weekly patient medications profiles.
19. Printing status changes
20. Process discharges
21. Entering care plans
22. Thinning out charts as required
23. Processing deficiency charts following proper procedure
24. Providing phone coverage for reception
25. Follows work schedule/instructions from supervisor.
26. Reports all unsafe/hazardous conditions, defective equipment, etc., to supervisor immediately.
27. Minimizes waste of supplies, misuse of equipment, etc.
28. Functions independently and demonstrates personal integrity, flexibility and the ability to work effectively with other personnel under varying circumstances.
29. Has knowledge of and follows Hospice policies and procedures.
30. Maintains a professional appearance.
31. Maintains a consistent positive attitude
32. Demonstrates Values of Hospice: PROFESSIONALISM * RESPECT * NURTURANCE * COMMUNICATION * CONTINUOUS IMPROVEMENT
33. Adheres to Hospice of El Paso Mission and Value Statement.

COMMUNICATION

1. Establishes and maintains effective communication and a cooperative manner with patient/family members, physicians, professionals and support staff working in hospitals, nursing facilities, foster homes, and other related facilities as required by position.
2. Establishes and maintains a cooperative manner and effective communication, both verbally and in writing, with all levels of Hospice staff.
3. Uses tact and sensitivity in communicating with patients/families, physicians, professionals and support staff working in hospitals, nursing facilities, foster homes, and related facilities as required by position
4. Complies with HIPAA standard by abiding with the minimum necessary Protection Health Information to perform job description responsibilities. Access level 3 = Select, insert, update and delete.

PROFESSIONAL DEVELOPMENT

1. Attends and participates in in-service education classes and on-the-job training programs as scheduled.
2. Attends conferences and workshops as approved.
3. Attend ethics and compliance training and maintains compliance with the CCP.

QUALIFICATIONS

1. Education and Experience
2. Must possess a high school diploma.

2. Technical/Other Skills

1. Familiar with personal computers, computer keyboard techniques, word processing, data base applications.
2. Knowledge of medical terminology desirable.
3. Minimum typing speed of 45 words per minute.
4. Must be able to read, write, and speak the English language.
5. Ability to learn to use computerized medical records application. On-the-job training provided in medical records procedures.

WORKING CONDITIONS:

1. Is subject to frequent interruptions and requests to perform differing job related duties.
2. May be required to work beyond normal working hours, weekends, holidays, and on other shifts/positions as necessary.
3. May be subjected to communicable diseases brought into the work environment by the field personnel.
4. Is subject to encounters with emotionally upset personnel, who are reacting to personal or patient-related matters. An ability to understand and deal with others needs and feelings is essential.
5. Exposure level. Category III- Tasks/activities do not entail predictable or unpredictable exposure to blood or other bodily fluids to which universal precautions apply.

PHYSICAL REQUIREMENTS:

1. Physically fit and able to work in a variety of settings and locations, primarily in well lighted/ventilated office area.
2. Sits, bends, lifts, and moves intermittently during working hours. Lifting should normally be items weighing up to 20 pounds.
3. Able to cope with the mental and emotional stress of the position.
4. Be a minimum of 18 years of age and of good moral character.
5. Possesses sight/hearing senses or uses prosthetics that will enable these senses to function adequately, so that the requirements of this position can be fully met.