The position maintains the medical records of the center in accordance with policies and procedures established for the medical record keeping practices.
Ability to establish procedures and to suggest changes for smoother operation.
Be able to type and understand the Medical Record Systems, including filing. Understand and utilize medical terminology, ICD-10-CM, coding principles, concurrent and Discharge Analysis Procedures, medical legal aspects and possess management skills for a nursing home.
Possess personal attributes to include professionalism, neatness, accuracy, articulates pleasantly and cooperative with all staff.
Education Background as follows:
MEDICAL RECORD TECHNICIAN:
Certification as an Registered Health Information Technician (RHIT).
Active member of the American Health Information Management Association (AHIMA).
Evidence of maintaining continuing education (CE) requirements of the American Health Information Management Association.
MEDICAL RECORD PRACTITIONER:
High school graduate or equivalent.
Minimum of 3 5 years of management or supervision in the field of medical records, preferably in nursing home setting.
Ability to read, write, hear and communicate adequately to complete job duties and responsibilities.
Ability to move throughout center without assistance.
Must be able to see adequately enough to read hand written medical records.
DUTIES AND RESPONSIBILITIES:
Are determined by the center and may include, but are not limited to the following:
Ensure upon admission of patients that the patient is properly registered in the necessary indices of the center (i.e., Patient Register and Patient Index); that patient is assigned a unit number; Admission Summery Sheet is properly and completely filled out and that the basic chart is assembled.
Determine upon admission of patients whether additional transfer data is needed and obtain missing information.
Make sure that patient's medical record number is on the patient armband, in addition to the other required information.
Check medical records quantitatively on admission and periodically (once per month minimum) to assure completeness, accuracy and internal consistency.
Communicate with and assist the medical staff and allies health personnel in updating the records. Interact with other departments, physicians, administrator and regional support staff.
Maintain flow of reports to the medical records.
Upon discharge, check records quantitatively to assure completeness and accuracy within thirty (30) days of the discharge or in accordance with state requirements.
Ensure that diagnoses have been listed according to ICD-10-CM and that abbreviated diagnoses are not recorded on the Admission-Summary sheet.
Maintain Patient Register, Patient Index and Diagnostic Index, updating each as changes occur.
Maintain overflow records.
Collect, collate and maintain statistical data as needed.
Provide information to Utilization Review Committee, Quality Assurance Committee, medical audits and others as needed or instructed by the administrator.
Maintain the numerical and unit numbering filing system for record identification.
Maintain sign-out and follow-up controls of records.
Maintain control count sheets for two years in separate file from the medical record in the absence of an in-house pharmacy.
Maintain and control the release of information to authorized personnel.
Type and/or transcribe reports or correspondence according to the needs of the Medical Records department.
Attend meetings as required by the administrator.
Be able to orient new employees to the procedure of the Medical Records department.
Credentialed individuals may assist as preceptors to local students of an MRT/MRA program.
Responsible for the evaluations, scheduling and tabulations of time cards and disciplinary action of medical record employees within the department.
Participate in development of and responsible for compliance with the budget of the Medical Records department.
Other duties as may be assigned from time to time.
NHC Place At Cool Springs