Medical Record Technician - Professional

NHC Place At Cool Springs Franklin , TN 37064

Posted 2 months ago

GENERAL PURPOSE

The position maintains the medical records of the center in accordance with policies and procedures established for the medical record keeping practices.

RESPONSIBLE TO:

Administrator

QUALIFICATIONS:

  • 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.

PHYSICAL DEMANDS:

  • 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.

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Medical Record Technician - Professional

NHC Place At Cool Springs