Medical records Nurse

·        Organize, plan and direct the medical records department in accordance with established policies and procedures.

·        Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.

·        Organize and maintain facility medical records system in compliance with corporate, state and federal regulations.

·        Code and quantify records from admission to discharge.

·        Maintain a documented, organized system which is readily accessible by other authorized professionals.

·        Ensure that all reports are completed within established time frames.

·        Schedule and maintain a time schedule for all interdisciplinary meetings and keep appropriate personnel informed of the schedule.

·        Maintain the resident census on a daily basis.

·        Maintain a current list of each physician’s residents and send to the physician quarterly.

·        Pull charts for physicians’ rounds each week and ensure that documentation is present.

·        Monitor Restrain and Bowl and Bladder Programs to ensure documentation is present.

·        Audit MAR and Treatment sheets weekly.

·        Audit Narcotic Count Sheets weekly.

·        Review admission information for accuracy and completeness within 24 hours of admission.

·        Conduct weekly audit of physician visits, progress notes, and nursing notes to ensure that all signatures and dates are present.

·        Conduct monthly audit of progress notes for all departments, monthly summaries, history and physical, etc. to ensure that all forms are present and complete.

·        Ensure that discharge records and chart are completed within 72 hours of discharge and arrange the file in chronological order in each section so that material can be retrieved in an efficient manner.

·        File lab and x-ray reports on charts daily.

·        Review physician orders (including telephone orders) and monitor to be sure that lab, x-ray, diagnostic tests, consultations, etc., have been scheduled and followed through.

·        Maintain log/roster to identify when care plan meetings are due.

·        Ensure that MDS quarterly review sheets are completed with each care planning conference.

·        Prior to admission, obtain the history and physical, admit orders, physician’s statement, TB skin test and/or chest x-ray.

·        Maintain resident admission register and discharge list.

·        Ensure that a Facesheet is completed for each resident. Make copies of the form and distribute to the authorized personnel involved in the resident’s care.

·        Prepare Resident Identifier and laminated name plate for the door for each new resident.

·        Maintain a list of residents hospitalized and dates of hospitalization.

·        Update individual hospitalization lists in charges including discharge summary from hospital.

·        Maintain a file of incident reports and ensure that the Director of Nursing and Administrator have seen and initialed the reports.

·        Prepare a monthly summary of incident reports for review by the Director of Nursing and subsequently the Medical Director.

·        Maintain a current list of diagnosis in each resident’s medical chart.

·        Maintain a master list of all residents including length of stay.

·        Prepare blank charts for admission if not utilizing electronic medical record.

·        File discharged charts, QA reports, minutes of meetings, consultant reports (all departments).

·        Prepare monthly report of deaths in the facility for Vital Statistics Department.

·        Thin charts according to facility policies and arrange overflow in discharge chart order.

·        Pick up and deliver lab specimens to the hospital.

·        Deliver forms, physicians’ reports, etc. to clinics.

·        Coordinate discharge and death records.

·        Collect medical records upon discharge or death, assemble in proper order, and check for completeness.

·        Return incomplete charts to nursing supervisor or attending physician for proper correction or completion.

·        Retrieve medical records according to medical records policy & procedure & send to the Chief Compliance Officer (Policy on SharePoint/Corporate Compliance).

·        Answer telephone inquiries and other correspondence.

·        Maintain confidentiality of all medical records.