Wilshire Lakewood Care Center Rehab & Healthcare strives for excellence!

Medical Records Reports To: Director of Nursing

Supervisers: Position requires no supervision of other staff members.

Medical Records Requirements: 

• Must have at a minimum a high school diploma or the equivalent.
• Must have at a minimum a limited ability to use computers.
• Must have understanding of chart and filing organizational systems.

Medical Records Duties:

·Maintain nursing/medical records mail log.

·Maintain record of admits and discharges

·Prepare new charts for incoming residents

·Place ICD-10 codes and diagnoses on facesheet and cumulative diagnoses sheet

·Close out charts for discharged residents

·Maintain an organized filing system for resident records

·Ensure that doctors have signed all necessary forms in chart including P.O. forms –this will require both mailing of the documents and communication with the doctors periodically

·Ensure that doctors perform annual physicals for each resident

·Audit each chart within 2 weeks of a new admit for necessary initial assessments (social services, dietary, activities, nursing)

·Audit each chart periodically for necessary documents including nurse’s notes, monthly summaries, weights and vital signs, doctor progress notes and physicals

·Thin charts every three months and/or at discharge

·File medical records in resident charts

oTelephone Orders

oMDS Records/Careplans

·Maintain stock of nursing forms at nurse’s station for use by staff.

·Assist in keeping nurses station clean and organized.

·Assist in responding to phone calls and family/resident concerns.

·Maintain nurses station fax machine including the replacement of ink cartridges and adding paper.

·Participate in quality assurance functions including but not limited to:

oActing as secretary to the quality assurance committee including but not limited to keeping minutes, scheduling meetings, and sending meeting notices.

·All other duties as assigned by supervisor.