MEDICAL RECORDS/UR ASSISTANT

ESSENTIAL JOB FUNCTIONS:

MEDICAL RECORDS

• Establishes new medical records folders and verifies correct name and medical record number for each new patient
• Locates and signs out medical records of patients readmitted to inpatient care and delivers the appropriate record as requested.
• Obtains verification of receipt of record.
• Retrieves current records of discharged patients and any corresponding records from previous admissions and returns them to the medical records department for processing.
• Locates and retrieves medical records for various reviews and studies.
• Responds timely to appropriate requests for information from outside sources
• Maintains stock of medical records supplies
• Performs other duties as assigned in keeping with the role and mission of the hospital.
• Maintains the Master Forms Binder.

• Reviews all closed medical records for correction of discrepancies or deficiencies and works to ensure that corrections/signatures/discharge summaries, etc. are completed. Maintains an accurate incomplete chart log of deficient records. Notifies Administrator of all incomplete charts monthly. Assigns appropriate diagnostic codes using CPT and International Classification of Disease System (ICD-10) for diagnosis.
• Determines and records other required data items such as attending physician, number of consultations, referral source, etc.
• Requests diagnosis from physicians when not recorded on discharge and in cases where information is incomplete.

CHARTS

• Maintains an adequate supply of forms to fill empty charts.
• Fills charts with appropriate forms in proper sequence and ensures that an adequate number of charts are available on the unit.
• Completes labels for each patient chart and labels each page.
• Flags open charts for signatures of physicians: Admit forms, labs, treatment plans, discharge plans, etc.
• Takes down charts of discharged patients and ensures that the closed record is complete and is in the correct order
• Revises forms as requested
• Maintains current list of "Don't Use" chart abbreviations

• Downloads reports from computer and monitors for discrepancies or deficiencies and makes appropriate corrections.
• Prints reports and places in patient charts within appropriate timeframes.
• Saves all reports on a diskette and also in the electronic transcription file
• Maintains the transcription file
• Notifies Administrator of any problems with dictation including but not limited to receiving the reports within specified timeframes

CLERICAL DUTIES - GENERAL

• Maintains a log of census reports
• Completes census report daily.
• E-mail daily reports to the appropriate management staff
• Complete the discharge report at the end of the month and email to the appropriate management staff
• Posts payments and applicable credits to accounts while maintaining balance sheets.