Medical Records Director directs medical record-keeping operations and healthcare information management to ensure secure, accurate, and reliable patient information management that complies with data and privacy regulations. Develops policies and procedures and conducts continuous improvement activities to ensure effective and compliant record management. Being a Medical Records Director implements digital technologies and tools to gain efficiencies, facilitate record retrieval, and ensure secure storage. Provides training for medical records staff and information resources to end-users. Additionally, Medical Records Director coordinates with clinical and technical professionals to maintain robust records management systems and manage data for analysis and reporting. Typically requires a bachelor's degree in healthcare administration, a related field, or equivalent. May require Registered Health Information Administrator (RHIA) certification. Typically reports to a director. The Medical Records Director typically manages through subordinate managers and professionals in larger groups of moderate complexity. Provides input to strategic decisions that affect the functional area of responsibility. May give input into developing the budget. To be a Medical Records Director typically requires 3+ years of managerial experience. Capable of resolving escalated issues arising from operations and requiring coordination with other departments. (Copyright 2024 Salary.com)
Rosewood Rehab and Healthcare Center strives for excellence!
Medical Records Reports To: Director of Nursing
Supervisers: Position requires no supervision of other staff members.
Medical Records Requirements:
Medical Records Duties:
· Maintain nursing/medical records mail log.
· Maintain record of admits and discharges
· Prepare new charts for incoming residents
· Place ICD-10 codes and diagnoses on facesheet and cumulative diagnoses sheet
· Close out charts for discharged residents
· Maintain an organized filing system for resident records
· Ensure that doctors have signed all necessary forms in chart including P.O. forms –this will require both mailing of the documents and communication with the doctors periodically
· Ensure that doctors perform annual physicals for each resident
· Audit each chart within 2 weeks of a new admit for necessary initial assessments (social services, dietary, activities, nursing)
· Audit each chart periodically for necessary documents including nurse’s notes, monthly summaries, weights and vital signs, doctor progress notes and physicals
· Thin charts every three months and/or at discharge
· File medical records in resident charts
o Telephone Orders
o MDS Records/Careplans
· Maintain stock of nursing forms at nurse’s station for use by staff.
· Assist in keeping nurses station clean and organized.
· Assist in responding to phone calls and family/resident concerns.
· Maintain nurses station fax machine including the replacement of ink cartridges and adding paper.
· Participate in quality assurance functions including but not limited to:
o Acting as secretary to the quality assurance committee including but not limited to keeping minutes, scheduling meetings, and sending meeting notices.
· All other duties as assigned by supervisor.
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