Medical Records Clerk
1 week ago
Job Summary: Performs the services of copying, chart assembly, analysis, and chart retrieval of patient medical records.
ESSENTIAL FUNCTIONS:
- Receive and process patient records following discharge.
- In an expedient, efficient manner, goes to the various units, picks up the prior day's discharges, and deposits the records in the coding area.
- Via computer reports, validates each record into the MRD post discharge: locates and secures any missing paperwork.
- Ensures all prior day discharges have been received and retrieves any missing paperwork.
- Accurate assembly/analysis (A&A) of records following discharge.
- Accurately analyzes the incomplete record to ensure compliance with regulatory standards and Medical Staff Bylaws, Rules & Regulations.
- Consistently meets performance expectations for A&A.
- Adding/resolving deficiencies within the computer system accurately.
- Tracks charts out of the department as requested using the computer system checking the chart out to the proper location and individual; requires signature page.
- Vital Statistics.
- Incomplete record process.
- Record retention/storage.
- Maintenance of the Master Patient Index.
- Charting transcribed reports twice daily to completion (includes routing copies as required).
- Meets established deadlines.
- Preps and scans records into electronic health record in a timely, efficient, accurate manner in order to facilitate timely coding.
- Participates in Performance Improvement and Quality Control Activities by data gathering, validation of data, and/or preparing accurate reports in a timely fashion, meeting deadlines.
- Consistently demonstrates behavior that reflects working as a team is more important than self-interest.
- Displays initiative to see processes through to completion and offers assistance without being asked.
- Responds to request in a timely manner.
- Demonstrates courteous and positive behaviors (i.e. smile, pleasant tone, good eye contact).
- Assist with other clerical duties within the department as assigned by Supervisor.
- Calculate/resolve chart deficiencies.
- Maintain chart location system.
- Assist physicians with incomplete record process.
- Maintain Master Patient Index.
- Prep and scan records into electronic health record.
- Maintain accurate record retention and storage.
- Performs other duties as assigned
- Basic computer knowledge
- Able to handle interruptions.
Information Management: Treats all information and data within the scope of the position with appropriate confidentiality and security.
Risk Management/Quality Management/Safety: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.
MINIMUM POSITION QUALIFICATIONS:
- Education - High school diploma or equivalent.
- Work Experience - Basic office skills, with good customer service; prior medical record experience preferred.
- Training
- License/Certification
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