Medical Records Clerk organizes, files, and retrieves patient medical records. Performs data entry, file maintenance, and other clerical processes. Being a Medical Records Clerk follows established policies and procedures to ensure effective and compliant record management. Fulfills information requests for retrieval and printing of medical records from storage or archives. Additionally, Medical Records Clerk ensures the privacy and security of all patient records. Requires a high school diploma. Typically reports to a supervisor. The Medical Records Clerk works under moderate supervision. Gaining or has attained full proficiency in a specific area of discipline. To be a Medical Records Clerk typically requires 1-3 years of related experience. (Copyright 2024 Salary.com)
POSITION DESCRIPTION:
Assists in developing and maintaining an appropriate health record service and system for the center.
QUALIFICATIONS
• High School diploma.
• Strong written and verbal skills in English necessary for business.
• Administrative and organizational ability.
• Knowledge of medical terminology.
• Previous experience in a skilled nursing home health care setting.
• Prior health record experience preferred.
• Basic computer experience preferred.
GENERAL DUTIES AND RESPONSIBILITIES:
ADMINISTRATIVE
• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and inservices.
TECHNICAL
• Initiates Resident Health Record.
• Initiates and maintains logs and indices as required:
• Admission/Discharge Register
• Master Patient Index
• Disease Index
• Medicare Log (if applicable)
• Audit System
• Discharge Control Log
• Chart Removal Log
• Resident Care Plan Log
• Telephone Audit Log
• Performs Audits
• Admissions
• Discharge
• Routine Quality Assurance Audits
• Special as required
• Coordinates Physician Documentation
• Telephone Orders
• History and Physicals
• Monthly Physicians Orders
• Physicians’ Progress Notes
• Certifications and Recertifications
• Discharge Summaries
• Thins charts and maintains overflow files as required.
• Records and maintains minutes of meetings as assigned.
• Inputs and prints computerized medical records forms.
• Prepares statistical reports as required.
• Destroys old health records as required.
• Assembles, analyzes and completes discharge records.
• Maintains unit filing system.
CONSUMER SERVICE
• Presents professional image to consumers through dress, behavior and speech.
• Adheres to Company standards for resolving consumer concerns.
• Ensures that all consumer/resident rights are protected.
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