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Form of work
SalarySUMMARY
Responsible and accountable for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long-term care facilities.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
§ Prepares charts for new admissions.
§ Closes Medical Records upon discharge.
- Develops schedule for and conducts audits of the clinical and electronic health records.
- Monitors physician visit schedule.
- Maintains master index system.
- Orders, maintains, and distributes Medical Records forms.
- Monitors procedures to maintain confidentiality of patient information and guard against loss or destruction of data in accordance with the facility’s policy and procedures.
- Maintains records and completes required forms and documents in accordance with facility policies and state and/or federal regulations.
ENTRY QUALIFICATIONS
- High school diploma or equivalent.
- Working knowledge of medical terminology.
- Proficient in the use of personal computer.
SUPERVISORY RESPONSIBILITIES
Supervises Medical Record assistant, if any, and others for whom they are administratively or professionally responsible.
