Medical Records Technician
4 weeks ago
POSITION SUMMARY
Conducts basic medical record review processes, including retrieving paper medical records from nursing units post patient discharge; preparing and scan paper medical records to ChartMaxx scanning module; analyzes ED, routine OB, newborn, and short stay surgery cases for completeness; processes the “discharge day”; and analyze charts on units.
EDUCATION/EXPERIENCE/TRAINING
Required:
• High School graduate or equivalent.
• One (1) year of recent experience in an acute care Hospital or large clinic Health Information Department. - 1-YEAR MINIMUM ACUTE CARE HIM EXPERIENCE
--> specifically seeking document analysis & document imaging experience in an acute care facility.
DUTIES AND RESPONSIBILITIES
1. Safeguards and preserves the confidentiality of patient’s protected health information in accordance with State and Federal (HIPAA) regulatory requirements, and hospital and departmental policies.
2. Ensures a safe patient environment and adherence to safety practices per policy.
3. Preps paper medical records for scanning, including checking all pages to verify that all belong to that patient.
4. Scan paper medical records to the ChartMaxx scanning module.
5. Verify scanned images are filed to correct document type, patient, and encounter.
6. Advises department supervisors of any new (unapproved) forms that are found in records.
7. Review the contents of the medical record to verify that all required sections and documents are complete.
8. Enters any physician deficiencies for ED, OB, Newborn, or SDC into the ChartMaxx Chart Completion Module.
9. Collects discharge charts from hospital units
10. Assures that patient identification is correct, and makes corrections as required.
11. Corrects reports in the Quality Assurance Hold.
12. Updates incomplete record status as necessary.
13. Prints and sends out faxes (and manual copies) on request.
14. Greets visitors and determines what services they require.
15. Responds to medical record requests for patient care information from telephone or fax requests
16. Performs all other duties as assigned.
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