Responsible and accountable for the record keeping procedures and storage of all medical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long-term care facilities.
Essential Duties & Responsibilities
- Prepares charts for new admissions.
- Closes medical records upon discharge.
- Develops schedule for and conducts audits of the medical records.
- Maintains the computerized physician order program and monitors physician visit schedule.
- Maintains master index system.
- Orders, maintains, and distributes medical records forms.
- Completes sections of the Minimum Data Set as required.
- Establishes and monitors procedures to ensure confidentiality of patient information and guard against loss or destruction of data.
- Maintains records and completes required forms and documents in accordance with company policy and state and/or federal regulations.
- Performs other duties as assigned.
- High school diploma or equivalent.
- Working knowledge of medical terminology.
- Proficient in the use of personal computer.
Physical Demands & Environment
Working in normal office environment, employee may be required to sit, bend, stoop, use keyboard, see, talk and hear. May occasionally lift objects of 10 to 25 lbs. In compliance with applicable law, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.