Medical Records Health Information Management

As Medical Records Director, you are the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. The primary purpose of your job position is to assure that the medical records are maintained in accordance with Federal and State Guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records is maintained. Medical Records Director must process and maintain private patient information in the health care facility’s database. Medical Records Director assess patient records to ensure they are complete and accurate.

• Enter data, such as demographic characteristics, history and, diagnostic procedures, or treatment into computer.

• Enter patient or treatment data into computers.

• Maintain, medical facility records or storage and retrieval systems to collect, classify, store, or information.

• Prepare medical records for Insurance and Legal Requests as required.

• Contact Physicians regarding incomplete charts.

• Assist Nursing staff and physicians with Death Certificates.

• Respond to requests for records from Federal, State or County Courts, Hospitals, Physicians and Insurance after getting direction from Administrator.

• Scan all Medical Records as Policy States, within 24 hours you receive documents.

• Perform chart Audits as follows:

• Admission Audits
• Weekly audits of physician visits, progress notes
• Monthly audits of progress notes for all departments, monthly summaries, history and physical, etc., to ensure all forms are present and completed.
• Discharge audit-Charts must be complete within 72 hours including discharge summary.

• Do weekly Audits to ensure that all Residents have a Complete Medical Record.

• Attend in-service education programs in order to meet facility educational requirements.

• Be familiar with Standard Precautions, Exposure, Control Plan, Fire Drill and Evaluation Procedures and know how to use them.