The Medical Records Clerk reports to and receives supervision from the Medical Records Supervisor or Chief Administrative Officer and performs a variety of clerical duties involved in maintaining medical records to include filing, retrieving and distributing medical records, and maintaining associated logs and records in accordance with established policies and procedures. The Medical Records Clerk is distinguished from the higher classification of Medical Records Supervisor. The Medical Records Clerk is an entry-level employee who performs routine clerical tasks.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Prepare, review, and maintain hard copy and electronic medical charts in accordance with established laws, rules, and regulations.
- Process new admissions.
- Prepare medical chart and enter data in computer system.
- Photograph the resident.
- Prepare Face Sheet.
- Update Admission/Discharge Register.
- Prepare and place name plate on resident’s door.
- Daily maintenance of medical charts.
- Transcribe physician orders, treatments and medications on a daily basis.
- Send unsigned physician orders to physician for signature.
- Document and follow-up to ensure receipt of signed order.
- File signed physician orders in the medical chart.
- Process face sheet changes, payer source changes, and room changes.
- Sort, file and collate medical records information such as admission slips, lab reports and clinical notes into resident medical charts in appropriate sequence and in accordance with established procedures.
- Research lost or missing records.
- Prints progress notes and other portions of the electronic record based on established policies and procedures.
- Process discharges.
- Update Admission/Discharge Register
- Remove name plate from resident’s door.
- Review medical chart to ensure a discharge note has been entered.
- Review medical chart to verify receipt of physician order for discharge.
- Send unsigned physician order for discharge to physician for signature. Document and follow-up to ensure receipt of signed order. File signed order in medical chart.
- Verify receipt of Discharge Sheet for each discipline recapping stay.
- Consolidate overflow records with medical chart and move medical chart to Discharge Records Storage. Maintain Daily Census and Admission/Discharge Register.
- Record admissions, discharges, transfers and deaths appropriately on a daily basis.
- Check census information against existing records for accuracy and completeness on a daily basis.
- Verify census information against existing records; research discrepancies, and make necessary corrections on a daily basis.Generate monthly reports and perform monthly audit of medical charts.
- Generate Resident PPD, Influenza, and Pneumonia Vaccination List on the first day of each month. Identity residents who need annual PPD, Influenza and Pneumonia Vaccinations. Enter resident names and due dates on the MAR and follow-up with nursing staff to ensure vaccinations are received and update medical charts.
- Conduct monthly medical record audits for compliance with policies and procedures.Thin medical charts on a quarterly basis.
- Pull Nursing Notes dated more than 3 months prior from the medical chart and file in overflow records
- Pull Physician Orders dated more than 3 months prior from the medical chart and file in overflow records
- Pull Progress Notes dated more than 3 months prior from the medical chart and file in overflow records
- Pull Lab Reports dated more than 3 months prior from the medical chart and file in overflow records
- Maintain confidentiality of medical records.
- Adhere to the confidentiality standards of the Privacy Act and HIPAA.
- Copy and distribute medical information as directed by the Medical Records Supervisor.
- The Medical Records Clerk reports to and receives supervision from the Medical Records Supervisor or the Chief Administrative Officer.
- Must possess, as a minimum, a high school diploma or equivalent.
PHYSICAL AND MENTAL DEMANDS:
- Must be able to lift and/or move up to 25 pounds.
- Must be able to work outside of normal work hours including nights, holidays, and weekends as needed to meet facility and position demands.
- Must be able to sit or stand or long periods of time.
- Must be free of diseases that may be transmitted in the performance of job responsibilities during the stage of communicability.
- Must be able to relate to and work with ill, disabled, elderly, emotionally upset and at times hostile people within the facility.
Work is usually performed in a typical office setting. Works beyond normal duty hours, on weekends and holidays when necessary. Interacts with residents, family members, and staff under all conditions and circumstances. Is subject to hostile and emotionally upset residents, family members, and visitors. Exposure to infectious waste, diseases, and conditions including but not limited to exposure to hepatitis B viruses.