Administrative Functions

• Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.

• Assist in organizing, planning and directing the medical records department in accordance with established policies and procedures.

• Assist the Medical Records/Health Information Consultant as required.

• Maintain minutes of meetings. File as necessary.

• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.

• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.

• Retrieve resident records (manually/electronically). Deliver as necessary

. • Files information such as nurses' notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.

• Collect, assemble, check and file resident charts as required.

• Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.

• Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.

• Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.

• Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized in our policies and procedures.

• Maintain a record of authorized information released from charts/records, i.e., type information, name of recipient, date, department, etc.

• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.

• Index medical records as directed by the medical records/health information consultant.

• Maintain various registries as directed including register for admission and discharge of residents.

• Transcribe and type reports for physicians as necessary.

• Collect charts, assemble them in proper order, and inspect them for completion.

• Pick up and deliver resident medical records from wards, nurses' stations, and other designated areas as necessary.

• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.

• Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.

• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)

• Assure that medical records taken from the department are signed out and signed in upon return to the department.

• File active and inactive records in accordance with established policies.

• Index medical records as directed.

• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.

• Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.

• Report any known or suspected unauthorized attempt to access facility's information system.

• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this position.