JOB SUMMARY
The primary purpose of your job position is to assure that 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 program is maintained.
As Team Assistant, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.
Every effort has been made to identify the essential functions of this position. However it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.
DUTIES & RESPONSIBILITIES
- Assist in planning, developing, organizing, implementing, evaluating, and directing the medical records section in accordance with established policies and procedures. (Includes department policies and procedures, job descriptions, etc.).
- Assist in establishing procedures to be followed in the collection, coding and indexing, and the filing/retrieving of medical records.
- Assist the Administrative staff as required.
- Advise the administrator on federal and state laws concerning medical records.
- Review discharge and death records, as well as records on the nursing units.
- Review department policies and procedures, at least annually, and participate in making recommended changes.
- Collect, assemble, check, and file resident charts and personnel records as may be necessary.
- Ensure that incomplete records/charts are returned to nursing service for correction.
- Assist in developing procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing.
- Ensure established policies and procedures for the medical records section are followed by all personnel.
- Assist in establishing procedures to ensure that charts/records are not taken from the section except as authorized. Periodically check such records to assure this policy is being followed.
- Assist in maintaining a record of authorized information taken from charts/records (i.e., type information, name of recipient, date, department, etc.).
- Abstract information from records as authorized/required for insurance companies, Medicare, etc.
- Assist in indexing medical records as necessary.
- Ensure that registries are properly maintained for admission and discharge of patient.
- Prepare medical records for court trials as required.
- Assume the authority, responsibility, and accountability of the medical records.
- Assist in the development and implementation of our written medical records policies and procedures.
- Devote such time, energy, and skill necessary to maintain accurate medical records.
- Provide written, dated, and signed reports to the administrator of each consultation visit.
- Obtain and maintain a suitable professional liability and malpractice insurance policy.
- Other related duties and responsibilities that may become necessary or appropriate.
- Follow written and oral instructions
- Maintain patience, tact, cheerful disposition and enthusiasm
- Must comply with all training requirements
Committee Functions (IDG)- Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. Attend such meetings as may be necessary or appropriate.
- Serve on various committees of the facility as appointed by the administrator.
Personnel Functions- 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 and problem areas can be identified and corrected.
- Assist in the recruitment and selection of department personnel as necessary or as may be requested.
- Conduct departmental performance evaluations in accordance with the facility's policies and procedures.
Staff Development- Assist in the orientation program for all personnel in accordance with our policies and procedures.
- Assist in the development of and participate in in-service educational classes and on-the-job training programs.
- Attend and participate in workshops, seminars, etc., as necessary.
- Develop and participate in in-service training programs for nursing services, and other related services.
Safety and Sanitation- Report all unsafe/hazardous conditions, defective equipment, etc., to the administrator.
- Ensure that work areas are clean and that records a