Address
Form of workPurpose of Position:
The Medical Records person maintains all Medical Records in compliance with local, State and Federal regulations. Works with outside agencies requesting and providing information, according to policy and regulations. In-services staff on Policy regarding maintenance, compliance and standards for Patient Medical Record. Applies the appropriate diagnostic codes to individual patient's health information for claims processing.
Description of Required Duties and Tasks:
Essential duties and responsibilities include the following.
• Maintains all patient Medical Records.
• Keeps safeguards of records in systematic fashion that uses a system of author ID and maintenance that ensures the integrity of authentication and protects security.
• Controls the records by implementing policies and procedures.
• Ensures that only authorized personnel have access to Medical Records, faxes, or electronic documents.
• Ensures records are secured and reasonably protected from fire, water, and other damage
• Assist with procedures to be followed for the back-up of records.
• Follows rules, regulations, laws, and accreditations of retention/destruction of records.
• Procedures for paper/electronic records
• Stopping destruction for legal process.
• Performs chart audits on all charts.
• Report to D.O.N or A.D.O.N. findings of chart audits pertaining to nursing so that any corrections or omissions or problems can be addressed.
• Assemble and disassembles charts upon admission and discharge.
• Works closely with other hospital personnel regarding chart order and completion.
• Ensures Medical Records contain information that is organized, clear, compute, current, legible, and timely monitoring that all entries are timed, dated, and authenticated.
• Ensures chart contain the following information within time frames as mandated by policies and procedures, laws, federal, state, and accreditations: H/P, consultative evaluations (results), consent forms, lab results, admission date, information for emergency contact, primary care physician (name, address and phone number), correspondence regarding patient, authorization of release of information, progress notes/nursing notes, treatment reports/plans, MAR records, vital signs, internal/referral source (person coordinated service), location of other records, insurance information, health history (assessments, screenings, past meds, hospitalizations), discharge summary.
• Ensure medical charts are completed, filed, and retrievable.
• Provides training to hospital staff regarding confidentiality and release of patient's Medical Records.
• Adheres and monitors for compliance of "Authorization of Release of Information".
• Responds to requests for patient/client information from individuals, family members, hospitals, physicians, attorneys, and others.
• Maintains the release of all patient Medical Records to outside agencies.
• Mails and/or faxes a copy of the Discharge Summary to the facility each patient is placed in. Also mails and/or faxes Discharge Summary to the attending physician and other agencies when it is requested.
• Understands and remains informed of current local, state and federal regulations regarding the maintenance, acceptance and release of Medical Records.
• Tags charts for completion and informs physicians or hospital personnel of incomplete notes, assessments, etc.
• Ensure a system of coding/indexing Medical Records (diagnosis).
• Assigns ICD-10-CM codes, creating DRG group assignment.
• Queries physicians when code assignments are not straight forward or documentation in the record is inadequate or unclear for coding purposes.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Performs Receptionist/Clerical duties when needed which include answering the phone, running facility errands, which includes taking blood work and other specimens to the lab, picking up and dropping off mail at the post office, picking up patient prescriptions at the pharmacy, making bank deposits and dropping patient information packets on each Friday to the Internal Medicine physician's office. Also make Admission packets, Nursing packets, and Patient handbooks.
• Provides back-up for receptionist.
• Keeps a log of calls taken and transferred regarding referrals.
• Cross trained in obtaining Medicare information.
• Responsible for making deposits and faxing the draft request form to THM when office manager is not in office.
• Responsible for making check received receipts when billing personnel is not in office.
• Download Doctors dictation to the transcriptionist.
• Works closely with Physician and utilizes a dictation audit log to insure his Progress notes, Comprehensives, Discharge summaries, and other necessary forms are dictated and received in a timely manner according to set policies.
• Works with Psych Doctor's private practice office manager to ensure she receives copies of all of the Doctor's dictation in done in our facility and any missing face sheets or patient insurance information she may call about.
• Daily print any work received from transcriptionist dictated by our Doctor for placement in each patients' chart and retains a copy of each piece of work for the Doctor's records.
• Works with transcriptionist to clarify any questionable spelling in the dictation, medicine, or physicians' names.
• Keeps up with all our Doctor's forms and keeps him supplied with copies when needed.
• Works closely with transcriptionist outside of facility to ensure timely receipt of all Physicians dictation.
• Works with Physician closely to proof read, correct and perfect his physician notes, H&P's, Psychiatric Evaluations and Discharge summaries and other documents.
• Works closely with substitute physicians to make sure we receive any dictation of progress notes and other Medical Records in a timely manner and making sure the original records are signed and back in the patients' chart in a timely manner.
• Attends meetings and in-services as required by Administrator.
• Performs additional job-related duties as required and necessary within the scope of the job responsibilities including taking the initiative to complete needed task that are unassigned.
• Recognizes and responds appropriately to prioritize all assignments on a continual basis.
• Demonstrates competency working with psychiatric and geriatric patients.
• Notifies Physical therapist of each discharged patient to obtain that patients final therapy documentation and therapy charges for billing personnel.
• Collects Psychiatric Metrics forms from each chart upon discharge to turn in to Administrator at the end of each month.
• Collects Protected Health Information Disclosure logs and fax confirmations from fax logs to turn in to Administrator at the end of each month.
• Collects information from chart audits performed and organizes and creates a detailed report monthly of those findings.
• Collects information and prepares a 72 Hour Billing Log, keeping up with the date a patient is discharged, coded date and the billing date to ensure compliance.
• Researches each patient's chart who was admitted in one month and is still here the 1st of the following month and collects information to produce at Preliminary Coding Report for estimated billing purposes.
• Keeps and updates a patient census record daily.
• E-mail a copy of the census to the transcription service daily.
• Fax a copy of the census to Ampharm daily.
• Keeps and updates the Alphabetical Listing for Medical Record Charts each month.
• Keeps records on patients admitted with Mental Retardation and a report is sent to the TN Division of Mental Retardation Services at the time that any patient is admitted who is identified with a diagnosis of mental retardation.
• Participates as a member of the Utilization Review committee.
• Adheres and respects all policies and procedures regarding anonymity and confidentiality of all patient records past and present. This covers any written or verbal communications regarding patient's identity, address, and situation.
• Functions in a friendly, supportive, courteous, respectful, cooperative, and professional manner with patients, families, physicians, referral sources, visitors, coworkers, and management.
• Promotes, adheres, and monitors for a drug and violence free work place.
• Meets the performance expectations of the hospital.
