Medical Records Clerk

Job Summary: Performs the services of copying, chart assembly, analysis, and chart retrieval of patient medical records.

ESSENTIAL FUNCTIONS:

• Receive and process patient records following discharge.

• In an expedient, efficient manner, goes to the various units, picks up the prior day's discharges, and deposits the records in the coding area.

• Via computer reports, validates each record into the MRD post discharge: locates and secures any missing paperwork.

• Ensures all prior day discharges have been received and retrieves any missing paperwork.

• Accurate assembly/analysis (A&A) of records following discharge.

• Accurately analyzes the incomplete record to ensure compliance with regulatory standards and Medical Staff Bylaws, Rules & Regulations.

• Consistently meets performance expectations for A&A.

• Adding/resolving deficiencies within the computer system accurately.

• Tracks charts out of the department as requested using the computer system checking the chart out to the proper location and individual; requires signature page.

• Vital Statistics.

• Incomplete record process.

• Record retention/storage.

• Maintenance of the Master Patient Index.

• Charting transcribed reports twice daily to completion (includes routing copies as required).

• Meets established deadlines.

• Preps and scans records into electronic health record in a timely, efficient, accurate manner in order to facilitate timely coding.

• Participates in Performance Improvement and Quality Control Activities by data gathering, validation of data, and/or preparing accurate reports in a timely fashion, meeting deadlines.

• Consistently demonstrates behavior that reflects working as a team is more important than self-interest.

• Displays initiative to see processes through to completion and offers assistance without being asked.

• Responds to request in a timely manner.

• Demonstrates courteous and positive behaviors (i.e. smile, pleasant tone, good eye contact).

• Assist with other clerical duties within the department as assigned by Supervisor.

• Calculate/resolve chart deficiencies.

• Maintain chart location system.

• Assist physicians with incomplete record process.

• Maintain Master Patient Index.

• Prep and scan records into electronic health record.

• Maintain accurate record retention and storage.

ADDITIONAL RESPONSIBILITIES:

• Performs other duties as assigned

KNOWLEDGE/SKILL/ABILITIES:

• Basic computer knowledge

• Able to handle interruptions.

AGE-RELATED COMPETENCIES: Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.

Information Management: Treats all information and data within the scope of the position with appropriate confidentiality and security.

Risk Management/Quality Management/Safety: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.

MINIMUM POSITION QUALIFICATIONS:

• Education

• High school diploma or equivalent.

• Work Experience

• Basic office skills, with good customer service; prior medical record experience preferred.

• Training

• License/Certification