This posting has expired and is no longer available.
Department: HEALTH INFO MGMT
Shift: Day shift
Hours: 40 Hours per Pay
The Medical Records Clerk is responsible for accurately creating and maintaining patient medical records as well as release of information. Duties will include filing, retrieval, copying, and forwarding for records (both internally and externally). The position is staffed on a five-day per week basis and may include both day and evening hours. The Medical Records Clerk may be required to deal with patients of all ages during the course of a normal workday.
High School education or equivalent.
Computer literate (i.e. Microsoft Office) and keyboarding skills at a minimum of 50 words per minute.
Familiarity with the health care environment and medical terminology is an asset.
Prior Clerical experience desired.
Essential Functions of the Job
Required skills and competencies. Has competency checklist been completed with all competencies met (i.e. job skills / knowledge, equipment knowledge)?
Responsible for creation of new medical records folders for patients not previously seen in the practice.
Responsible for release of information according to est. protocols.
Accurately maintains records for existing patients to include: electronic filing, chart organization.
Update patients' information in computer system.
Answers telephone and responds to inquiries in a timely, professional, courteous and helpful manner.
Pull records for ER and Clinics.
Checks daily discharge log to ensure receipt of all records and follows up on records not received.
Ensures that all patient records are received within two days of discharge, reporting to Manager and Nursing Supervisor on the appropriate floor when unable to obtain a patient record.
Checks each patient record for poor originals and stamps with 'poor original? stamp according to procedure.
Removes all photographs and other difficult to scan documents from the record and replaces with alternate media page. If document is damaged, copies for scanning.
Securely attaches rhythm strips and other small documents to 8 ½ x 11 paper for scanning.
Ensures the patient name, encounter number and the medical record number are documented on 'photograph cover sheet?.
Prepares all documents in date sequence from admission to discharge date.
Grouping like documents types together, in page and in date order.
Removes COLD fed documents from each record (transcribed reports, labs etc.)
Prepares batch by placing batch cover sheet on each batch and placing rubber band around batch.
Retrieves records from scanning shelf and performs scanning process according to procedure and within established time frame.
Maintains appropriate set up for scanner to ensure optimal results.
Verifies that each batch has been prepped appropriately, removing documents that cannot be scanned and removes staples, paperclips, etc.Assigns batch label according to procedure.
Identifies pages that did not scan well and flags fro scanning on flatbed scanner.
Writes batch to the correct work queue.Cleans scanner on a weekly basis according to instructions.
Places completed batches in appropriate area for indexing.
Selects appropriate assignments for analysis from the work queue.
Reviews each record for missing documents, missing signatures or missing text according to procedure.
Assigns deficiencies to physician according to procedure.
Links signature deficiencies for COLD fed documents to provider.
Correctly identifies when dictation has not been done and assigns to the correct provider.
Monitors reanalysis queue daily and reassigns deficiencies when appropriate.
Ensures that all scanned documents are positioned correctly.
Indexes documents to the correct encounter and document type.Correctly appends pages/documents when and where appropriate.
Writes each batch to the appropriate queue according to workflow.
Final check of charts before releasing into HPF.
Maintenance of medical records (electronic, making new folders, volumes, purging, death files to storage, etc.)
Handling incoming telephone calls.
Photocopy and follow up of Advance Directives.
Photocopy and distributing EKGs.
Faxing using confidentiality protocol.
Assists in retrieving charts for physician completion.
Responsible for maintaining security and confidentiality regulations for record access and review.
Consults manager or supervisor of any unusual requests.
Scanning documents into ECW (electronic medical record.
All other duties assigned by Manager.
Job Code: 71804836
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