Summary of Duties:

Under the direction of the Director of Nursing Services (DON) and with consultation from the Medical Records Consultant, the Medical Records Designee maintains the clinical records in accordance with State and Federal Regulations as well as professional standards of practice and facility policies and procedures to ensure complete, timely, and accurate clinical records. The Medical Records Designee is responsible for managing all aspects of the clinical patient record from admission to discharge.

Supervision:

The Medical Records Designee is under the direct supervision of the facility’s Director of Nursing.

Qualifications:

High school diploma required; Associates degree in Medical Record Technology preferred; Completion of classes in medical terminology and knowledge of HIPPA.

Other Training, Skills and Experience Requirements:

Filing, computer skills, knowledge of medical terminology, keyboarding.  Employee must demonstrate on an ongoing basis the ability to develop and maintain good working relationships with co-workers and other departments.

Position Requirements:

One to two years previous experience in medical records; previous typing and office experience preferred.

Essential Functions (with or without reasonable accommodations):

The duties and responsibilities included under the essential functions listing have been determined by management to be essential to the successful performance of this position.  However, this listing may not be inclusive of all the duties and responsibilities that may be required.  The omission or exclusion of duties and responsibilities from this description does not infer that the designated employee will not be required to perform additional job-specific duties if the work is similar, related or becomes an essential function of this position.

Physical Requirements:

The employee must be able:

• To move intermittently throughout the work day
• See, hear or use prosthetic devices to enable use of the senses adequately
• Assist with the evacuation of elders if necessary
• Bend, stoop, sit for extended periods of time
• Dexterity of hands and fingers to operate equipment
• Ability to lift, move, push or pull a minimum of fifty (50) pounds

Work Environment:

The primary work environment is throughout the facility and at times the work is stressful.  The employee may be exposed to blood, body fluids, infectious diseases and air contaminants.  The employee may be subject to work call-back during times of facility emergency or disaster preparedness functions. This is an extremely sedentary position where the employee is required to sit for prolonged periods of time.  Employee is able to sit and stand as tolerated. Employee must be organized and detail-oriented.  Employee may be requested to perform other duties or tasks that are not listed, but are within the competence and training of the individual.

Summary of Occupational Exposures:

Bloodborne Pathogens:

Tasks and procedures performed by employee involve risks classified by CDC as: Category III (Task/activity does not entail predictable or unpredictable exposure to blood.)

Specific Task Exposure:

• General Elder Care: Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions other body fluids-cerebrospinal, synovial, pleural, peritoneal, pericardial
• Handling soiled linens and clothing: Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions, other body fluids-cerebrospinal, synovial, pleural, peritoneal, pericardial
• Cleaning elder rooms and common areas-Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions
• Refer to Exposure Control Plan for additional information

Confidentiality of Information:

• The employee in this position may not disclose any record (via any media format, known or unknown
• May not disclose any elder or facility information, any system log-in codes or password assigned or permit any unauthorized access to elder/resident or facility information without express written consent of the facility management

Fair Labor Standards Act:

This facility’s compensation for this position exceeds the mandates of the Fair Labor Standards Act and as such this position is exempt from overtime coverage

Position Acknowledgement:

By accepting this position, the employee agrees to perform the tasks outlined in this job description, as well as other tasks that may become necessary to the position.  Failure to perform the duties in a safe and professional manner and in accordance with the facility established policies and procedures may result in disciplinary action including termination of employment.  The employee will receive a copy of this job description and a signed copy will be placed in the employee’s personnel employment file.

Essential Duties and Responsibilities:

Under the supervision of the facility’s Director of Nursing, provides services to organize and maintain all clinical records of elders residing in the facility by performing the following essential functions:

• Processes admissions and all pertinent paperwork
  • Compiles admission packets
• When called upon, answers facility telephone promptly and acts as facility communication source
• Files all medical record paperwork in chart as directed
• Transmits physician orders to pharmacists
• Makes door plates for all new admissions
• Makes physician appointments and arranges transportation
• Maintains nursing forms inventory
• Prepares necessary paperwork for emergency transfers and makes copies necessary for physician appointments
• Orders supplies, equipment and equipment repairs as requested
• Treats all elders, visitors and staff with courtesy
• Responsible for auditing and thinning all clinical records
• Closes and files discharged elder clinical records
  • Reviews charts of discharged elders for the deficient information and ensures compliance for correction of deficient documentation
• Files elder medical information in the elder’s clinical record in a chronological manner
  • Assures that each section of the elder’s record is maintained in a neat, organized and readable format
• Ensure that Physician orders, telephone orders and other records requiring signatures are received and filed within the required time frames
• Maintains effective communication with others, both inside and outside the department, to give or obtain needed information or coordinate activities of elders, such as doctors’ appointments
• Ensures that all elders are seen by their chosen physician(s) and routine laboratory work is completed and filed in the required time frames
• Assures personal and staff compliance to all State and Federal regulations including blood borne pathogens, infection control, use of hazardous materials and fire safety
• Assures personal and staff compliance to Residents’ Rights
• Attends and participates in in-service training, performance improvement committees and other meetings as scheduled and directed
• Safety
  • Knows and follows facility rules
  • Demonstrates proper use of equipment
    • Report equipment needs or repairs
• Follows facility smoking policies
• Reports and documents any incidents or accidents of elders, staff or visitors to appropriate facility personnel
• Performs duties which may include transportation of elders, as assigned in Facility Disaster Plan
• Uses required protective equipment
• Follows infection control standards, policies and procedures
• Reports all hazardous conditions/equipment to Supervisor
• Reports resident/family complaints to management immediately
• Complies with all laws and regulations applicable to position and acts in accordance with the facility’s Corporate Compliance Program
• Other duties as assigned