Job Description
Maintain medical records in accordance with federal and state guidelines, as well as in accordance with our established policies and procedure. Acts as clerk on the Nursing Units to assist in all non-professional task and duties.
Administrative Functions - Is the custodian of medical records to include coding,
- auditing of discharged records and insuring completion of same.
- Prepare and set up for all new admissions and update information as needed.
- Deletes forms when indicated and maintains all residual files. Follows chart audit/ deletion policy.
- Responsible for quality assurance of closed and open medical records.
- Logs all admissions, discharges, and transfers of residents.
- Reviews all monthly vital signs for completeness and documents in chart.
- Collect charts, assemble them improper order, and inspect them for completion
- Retrieve medical records when requested by procedure
- Reviews all monthly vital signs for completeness and documents in chart.
- Monthly - monitors all Treatment Administration Records, Psychotropic Medication Records, and Medication Administration Records for completeness and then files them in resident’s medical record. Determines what signatures are missing and contact appropriate staff member to complete.
- Check for correct name and room number on all sheets and put heading on as necessary.
- Place appropriate sticker on charts, i.e. DNR, Allergies, Advance directives etc.
- Arrange storage of supply in a neat and orderly fashion on unit.
- Keeps stock forms well supplies in drawers in alphabetical order.
- Keep CNA book up to date.
- Pick up mail from mailbox for both units.
- Order office supplies and maintain par level.
- Answer phone on unit and identify self. Takes messages accurately and transcribes legibly.
- Street clothes are neat and clean at all times, not be confused with Nurses Aide’s.
- Covering for the nursing secretary at the front desk her lunch break.
- Covering for central supply/staffing coordinator during her absent.
- Be available to the unit managers when necessary.
- Other duties as assigned by the Director of Medical Records.
Staff Development - Attend and participate in in-service educational classes and on-the-job training programs as directed.
- Attend and participate in workshops, seminars, etc., as approved.
- Create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the facility.
- Attend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and bloodborne pathogens standard.
Safety and Sanitation - Follow all established safety procedures and precautions when operating office equipment.
- Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
- Follow established regulations governing the use of labels and MSDSs for hazardous chemicals within the department.
- Follow established ergonomics policies and procedures governing lifting techniques, repetitive tasks, and the use of safety equipment and supplies to prevent work-related injuries and illnesses.
- Report all unsafe/hazardous conditions to your supervisor immediately.
- Other(s) that may become necessary/appropriate to assure that the facility is maintained in a clean, safe and sanitary manner.
Equipment And Supply Functions - Ensure administrative supplies have been replenished in work areas as necessary.
- Use office supplies in an efficient manner to avoid waste.
- Request repairs for office equipment as necessary.
- Ensure that work/assignment areas are neat, clean, and office equipment is covered before leaving such areas on breaks, end of work day, etc.
Experience - Must have at least 3 month(s) experience in a clerical position, or successfully completed a secretarial science program from an accredited school/college.
- Some knowledge of medical records and terminology.
- High school graduate, prior work experience with documented competence in completing variable job requirements.
We are proud to offer: - Competitive Rates
- Healthcare benefits (medical, dental and vision)
- Paid time off
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Job Tags
Work experience placement, Immediate start,