Summary:
The primary purpose of this position is to maintain medical records in accordance with federal and state
guidelines, and in accordance with our policies and procedures, to assure that a complete medical records
program is maintained.
Essential Job Functions:
• Assist in organizing, planning & directing the medical records section in accordance with
established policies and procedures.
• Maintain a working rapport with other departments in the facility to assure that medical records
can be properly maintained.
• Assist in recording all incidents/accidents. File in accordance with established policies and
procedures.
• Collect, assemble, check, and file resident charts and personnel records as required.
• Ensure incomplete records/charts are returned to nursing service for correction.
• Assist in developing procedures to ensure records are properly completed, coded, signed,
indexed, etc., before filing.
• Establish a procedure to ensure charts/records do not leave the section except as authorized in
our policies and procedures.
• Maintain records of 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,
Medicaid, VA, etc.
• Maintain various registries as directed including register for admission and discharge of
residents.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Perform miscellaneous duties pertaining to medical records and assist business office personnel
as required/directed.
• Assist in admission, transfer and discharge procedures as necessary.
• Answer telephone inquiries concerning medical records functions. Prepare written
correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses,
government agencies, etc.)
• Assure that medical records taken from the department are signed out and signed in upon
return to the department.
• File active and inactive records in accordance with established policies.
• Index medical records as directed.
• Other duties and responsibilities that may become necessary or appropriate to meet the
administrative needs of this facility.
Qualifications:
• Must possess, as a minimum, a high school diploma or equivalent.
• Must have knowledge of medical terminology
• Must possess a current, unencumbered, active license to practice as an RN or LPN in this state.
• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such
action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors,
government agencies/personnel, and the general public.
• Must possess the ability to plan, organize, develop, implement, & interpret programs, goals,
objectives, policies & procedures, etc., that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to
handle difficult residents.