MEDICAL RECORDS COORDINAT

 Brief Description of Duties

Assure medical records are in compliance with facility policy and procedure, local and referral regulations.

Secure records and ensure confidentiality.  Responsible for the training and supervision of the unit clerks.



CHARACTERISTIC RESPONSIBILITIES

Maintain confidentiality of all medical record information.

Assure that charts are organized and sectioned properly.

Complete admission register and resident index cards.

Code and index medical records using ICD 9CM System.

Release information with appropriate consent and approval according to facility policies and procedures.

Maintain current over-flow records.

Assure charts are closed in a timely manner.

Prepare statistical analysis reports as requested i.e., deaths and discharges.

Shred charts after 5 years retention limit has expired.

Perform other duties and assume responsibilities as requested by supervisor.

Maintain files in appropriate order.

Ensure that all pages of the medical record include residents’ name.

Documentation for closure of records.



WORKING CONDITIONS/PHYSICAL EXERTION

Work in clean, well-lighted, heated and ventilated office.

May be exposed to communicable diseases in the course of work.

Possibility of strains/sprains moving residents or injury from a confused resident.

DUTY HOURS

Minimum of 40 hours per week, or whatever is required for efficient job performancE.

Is classified as non-exempt and is eligible for overtime pay under the Fair Labor Standards Act.



MINIMUM ENTRY QUALIFICATIONS

High School diploma or equivalent. Bachelor’s preferred.

Medical or records clerk experience preferred.

Medical Records Certification preferred or willingness to attend and complete program.

Long Term Care and/or ICD 9CM Coding experience preferred.

Basic computer knowledge of WordPerfect and Lotus 1-2-3 required.