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SalaryPosition Summary
The Medical Records Staff manage medical information records, which include both electronic data and paper files. They organize and keep track of patients’ medical histories and test results, both for facility, doctor, insurance and legal use. Medical Records Staff use ethical principles and decision-making skills, and the knowledge of local, state, federal and other regulatory requirements necessary for the long-term care industry.
Position Responsibilities
The Medical Records staff has in-depth knowledge of medical technology, processes, and administrative duties. This position must demonstrate excellent communication and organizational skills. Responsibilities of the Medical Records Staff include (but are not limited to):
- Promotes and maintains a focus of patient-centered care
- Adheres to laws, rules & regulations and practices ethical integrity and interpersonal skills
- Maintains compliance with long-term care regulations including federal, state and health regulations
- Responsible to the Director of Nursing for ensuring accuracy, accessibility, and security of data
- Proficient in computer applications, data security and data analysis including the process and use of electronic health records (EHR)
- Gather patient demographic and personal information
- Issue medical files to persons and agencies according to laws and regulations
- Distribute medical charts to the appropriate departments of the facility
- Maintain quality and accurate records by following facility procedures
- Ensure patient charts, paperwork/electronic documentation and reports are completed and/or submitted in an accurate and timely manner
- Make sure all Medical Records are protected and kept confidential
- File/store all patients’ Medical Records and information
- Supply the nursing department with the appropriate documents and forms as applicable
- Complete clerical duties including answering phones, responding to emails, and processing patient admission and discharge records as applicable
- Promote and set the example for resident rights helping protect and enhance those rights
- Perform position duties in a manner as to assure resident safety and rights are priority
- Adheres to the facility corporate compliance program and promotes the program in a positive and effective manner
- Performs other position-related duties as assigned, depending on assignment/shift setting
Other Responsibilities
- Follows facility OSHA safety rules and procedures
- Follows facility policies and procedures and adheres to federal and state regulations for long-term care
- Respects cultural and religious practices of patients
- Upholds HIPAA regulations
- Maintains a punctual and dependable attendance record
- Position Requirements
- High school diploma or equivalent qualification
- Minimum of (2) years LTC experience, preferred
- Federal, State, and MHI required credentials current and on file
- Cognitive skills as related to the position
Working Conditions
Because the nursing home provides round-the clock care, working hours may include days, nights, weekends and holidays. An Administrator works in a climate controlled and well-lighted environment with a smoke-free policy. Works in an office and walks throughout the building daily. Has a low risk of exposure to infectious diseases, but receives training in handwashing practices and has access to personal protective equipment if direct exposure is anticipated. Is subject to interruptions, noise, and odors daily.
Physical Demands
- Long periods of sitting at a desk and working on computer. Prolonged periods of standing, bending, and reaching
- Lifting and carrying continuously. The ability to lift up to twenty (20) pounds occasionally. Assistance in moving, lifting or transferring of patients may involve lifting of up to fifty (50) pounds occasionally.
- Fine motor skills
- Visual acuity
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. While performing the duties of this job, the employee is regularly required to stand and talk or hear. The employee is frequently required to walk; use hands to finger, handle, or feel; and reach forward with hands and arms. The employee is occasionally required to sit and stoop, kneel, or crouch. The employee must occasionally lift and/or move up to 20 pounds and occasionally lift or move 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
Physical Demand Ratings are an estimate of the overall strength requirements that are consider to be important for an average, successful work performance of a specific job. The overall physical demand rating for a Medical Records Staff falls within the medium classification (10 to 20 pounds of force occasionally and/or exerting 20 to 50 pounds of force occasionally. Physical Demand requirements are in excess of those for Light Work.
