Medical Records Assistant

Found in: Lensa US P 2 C2 - 2 weeks ago

Anderson, United States Oak River Rehab Full time

POSITION:The Medical Records Assistant is to perform accurate and timely transcription of physician, nursing and other provider orders; computer order entry; maintaining resident medical charts and communicating pertinent information to staff members. QUALIFICATIONS/REQUIREMENTS:High School graduate or equivalentRequired Previous experience in medical records preferredESSENTIAL JOB FUNCTIONS:Transcribe, accurately, physician and nursing orders on appropriate documents in a timely mannerAssure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as requiredRecord accurate, legible information about resident care and condition in appropriate sections of resident's recordsFollow facility policies and procedures including those related to infection controlCapable to perform new duties as assigned and trainedMaintain resident medical charts, station documents and suppliesInput physician and nursing orders to computerEstablish and maintain effective communication both written and verbalAble to interact effectively with individuals who are cognitively and/or physically impairedOrganize nursing stations and maintain a tidy work environmentPerform chart audits as assignedDemonstrate ability to maintain confidentiality of resident and facility informationPrioritize workload and complete projects accurately and in a timely mannerAssist with preparation for state inspections as directed. Attend survey training and interact with state surveyors as directed by immediate supervisorDemonstrate interpersonal skills that contribute to a positive work environmentDemonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactionsProvide excellent service to staff, visitors, and residentsAnswer telephone professionally and in accordance with facility policyDemonstrate competence in use of proper body mechanics for both upper and lower bodyMonitor physical environment for safety or fire hazards and corrects or reports potential problems immediately to Charge Nurse. Promptly reports housekeeping and maintenance problems to Charge NurseReport injury to resident or self to Charge Nurse immediatelyParticipate in fire and disaster drills. In the event of any emergency, carries out assigned duties to assure resident safetyKnowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond to written or oral instruction in case of emergencyAdhere to policies and procedures

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