Medical Records Director jobs in Chico, CA

POSITION:

The Medical Records Director assumes authority, responsibility and accountability for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards and county, state and federal laws and regulations, as applicable, for long term care facilities. Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible and systematically organized.

QUALIFICATIONS/REQUIREMENTS:

• High School graduate or equivalent
• At least on year of clerical experience, including filing

• Experience as a medical records practitioner in long term care facility preferred
• Ability to type, calculate and perform data entry skills

ESSENTIAL JOB FUNCTIONS:

• Perform health record maintenance duties; assembling, labeling, cleaning, filing and purging documents
• Maintain stock of forms and record supplies
• Request necessary resident information from transferring facilities
• Process external information requests from authorized institutions and individuals
• Compile statistical data at the direction of Administrator
• Prepare Alirts (OSHPD) yearly report
• Maintain the confidentiality and physical security of health records in accordance with HIPPA rules and regulations
• Perform concurrent and discharge quantitative audits of health records. Physician visit audits. Notification of physician when required by procedure
• Develop and perform specialized audits on a predetermined time sequenced rotation with plan of completion to be defined and time limited. Audit all current resident charts to notate deficiencies and obtain and assist in corrections on a scheduled basis. Submit deficiency reports and to persons responsible for correction with date of completion to be returned (3 days) to the Administrator, Director of Nurses or designated representatives. These audits will include but are not limited to:
  • Admission audits within 24 or 48 hours,
    7th 14th and 21st day
  • Skin and pressure sores
  • Foley Catheter, Intake and Output
  • Diabetic
  • Special Therapy, i.e., IV, PT, OT, Inhalation, Tube Feeders, etc.
  • Psychotropic
  • Nursing Weekly Progress Notes
  • Bowel and Bladder
  • Medications and Treatments
  • Telephone Orders
  • MDS – Initial, Quarterly, Yearly, Change in condition
  • Intensity of Care Directives
  • Discharge Charts
  • Weights – Weekly/Monthly
  • ADL records
  • Lab/X-Ray
  • Medicare Q shift Charting
  • Current H and P
  • Physician Visits
  • Plan of Care – entries of each discipline
  • Change in condition – Daily
  • Quarterly Progress notes – Activity, Dietary, Social Service, Discharge Planning.
  • Accidents/Incident Reports
• Disease index coding at time of admission, when diagnostic status alters and within 30 days of discharge date. Complete any outstanding disease index coding
• Discharge charts must include the following information prior to filing:
  • Final Diagnosis and/or Death Certificate
  • Completed Disease Index Coding
  • Obtain all outstanding documentation and required signatures to meet criteria mandated by facility policy.
• Mail telephone order forms to physicians daily, assure prompt return and file in chart
• Prepare Physician Orders, Medication/Treatment records, ADL records and Resident Care Plans for accurate input into computer and printing on scheduled basis
• Perform computer operation functions including regular input of data and printing on a scheduled basis
• Keep computer terminal(s), keyboard(s) and office clean and functional
• Maintain appropriate medical record storage and destruction of medical records consistent with facility policy
• Follow-up on reports and recommendations submitted by the Medical Records Consultants and Service Center Medical Records Analysts
• Report to the Director of Nursing and Administrator significant documentation problems
• Attend and participate in in-service education and staff meetings as required, including risk management and daily stand-up meetings. Maintain minutes of meetings/files as requested
• Be courteous, considerate and cooperative when communication with all facility personnel, resident and public
• React appropriately to emergencies and disaster situations