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
- Recruits, hires, provides orientation/training, and retains a sufficient number of qualified staff to carry out the responsibilities of the Medical Records area. Ensures employee performance meets or exceeds expectations and periodic performance appraisals are conducted on a timely basis.
- Directs the preparation of charts for new admissions.
- Closes medical records upon discharge.
- Develops schedule for and conducts audits of the clinical 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.