Responsible for maintaining the medical records for Post Acute Services in accordance with accepted standards and agency policy.
1.Processes all forms that need to be mailed/emailed/faxed/websig:
a. Medical plan of treatment/physician orders.
b. Release of information for medical records.
c. Process order runs, review orders post Nurse Coordinator submission
d. Fax/mail the Plan of Care (POC) for Primary MD signatures, post completion of the POC document. Notifies supervisor upon Primary MD non-responsiveness or any changes in the Primary MD status concerning the patient (inc. discharge summaries).
e. Mail out service evaluation forms to the patients PMD.
f. Notification to funeral home, coroner, local emergency medical system, etc., as appropriate.
2.Creates open chart for all newly admitted patients.
3.Receives all clinical admission forms, distributes copies to appropriate personnel, and incorporates originals in the open chart
4.Retrieves, Manages, Processes and tracks all documents including verbal orders, plans of care, Face to Face documents, physician orders, and recertification of prognosis as required.
5.Files all paper documents into the Patients Hard Copy Chart timely (within 1-2 weeks).
6.Scan and attach specified paper documents into Electronic Medical Record.
7.Ensures timely receipt and maintains a tickler file for outstanding orders, etc. Reviews file regularly and follow up on non-returned.
8.Upon death or discharge of patient, transfers open chart to closed chart and prepares bereavement file where applicable. Processes discharge summary.
9.Audits all DC charts prior to storage shipment.
10. Other duties as assigned.
High School diploma required. Knowledge of Windows PC applications and medical terminology.
At least one-year of previous clerical experience, preferable in a medical setting. Certificaiton in Medical Record Information Technology.
Good verbal and written communication skills with knowledge of medical terminology. Operatines computer generated clinical record programs.
Ability to coordinate daily clerical projects for timely completion. Highly organized, excellent telephone skills, typing and clerical skills. Excellent organizational skills required.
Job requires extensive sitting, telephone communication, viewing of a computer screen and handwritten documents. May need work schedule to be flexed to accommodate Departmental needs.
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