Job Details
Description
Maintains the Facility’s medical records according to established guidelines and requirements. Reviews records for compliance with approved policies. Assures all operative reports completed.
Minimum Requirements
- Good communication skills required
- Two years clerical experience preferred
- Medical Clerical experience preferred
- Requires language skills adequate for written and interpersonal communication in American English
- Requires visual and auditory acuity adequate for frequent use of computers and occasional use of other business office equipment
- Ability to sit for long periods and to perform desk and office activities
Essential Functions
- Assumes clerical duties and responsibilities as necessary.
- Coordinates obtaining diagnostic test and places diagnostic test reports in appropriate section of patient medical record.
- Assists with preparation and maintenance of Facility records and reports.
- Generate and distribute Physician Check List monthly.
- Prepares CQI report from Physician Check List responses.
- Coordinates the collection, processing, maintenance, storage, retrieval and distribution of medical records according to established policies and procedures.
- Maintains a filing system that meets Facility requirements for medical records.
- Provides organized storage system for timely retrieval of individual medical records and maintains charge-out and follow‑up controls of records.
- Maintains the confidentiality, security and physical safety of Facility medical records.
- Provides information, according to confidentiality policies, to those parties who are engaged in research or study projects involving patient care and utilization of services.
- Reviews medical records for timely completion, accuracy and for compliance with PRO generic screens; informs the Facility Administrator about delinquent or incomplete medical records.
- Adheres to established procedures for cross referencing and indexing medical records.
- Maintains necessary index‑references for Facility needs and following established procedures.
- Maintains the admission register and all other systems involving patient information.
- Maintains the physician/procedure index.
- Collects statistical data relevant to the operation of the Facility.
- Reviews the contents of medical records to identify information to be extracted.
- Prepares and presents data and reports on approved forms.
- Completes vital statistics on deaths and reportable diseases.
- Upon request, provides information to those involved in research projects and studies.
- Collects data required for support of continuous quality improvement activities.
- Adheres to medico-legal requirements when answering correspondence and inquiries.
- Maintains and controls the release of information to authorized persons only.
- Prepares records or correspondence according to Facility needs.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools, or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.
The employee must be able to lift and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.
The employee must be able to stand and/or walk at least five hours per day.
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
