Medical Records Assistant

Overview

This position is responsible for managing resident medical records and health information systems, ensuring compliance with federal and state regulations as well as facility privacy policies.

Key Duties

• Follow supervisor instructions and schedule in line with facility policies.
• Support organization and management of the medical records department.
• Assist Medical Records/Health Information Consultant as needed.
• Record and file meeting minutes properly.
• Coordinate effectively with other departments to maintain accurate medical records.
• Document incidents and accidents as per policies.
• Retrieve and disseminate resident records both manually and electronically.
• File nurses' notes, assessments, progress reports, labs, x-rays, and correspondence into resident charts.
• Collect, assemble, verify, and file resident charts.
• Help the MDS Coordinator schedule assessments following facility and OBRA guidelines.
• Ensure incomplete charts are returned for correction.
• Develop procedures to ensure accuracy and completeness in medical records prior to filing.
• Control access to resident charts, ensuring they do not leave the medical records room unapproved.
• Maintain logs on authorized information release including type, recipient, date, and department.
• Abstract data from records for insurance and government agencies in compliance with privacy regulations.
• Index medical records as directed.
• Maintain registries such as resident admission and discharge logs.
• Transcribe and prepare medical reports as required.
• Collect, organize, and check charts for completeness.
• Retrieve and deliver medical records to wards and designated areas.
• Batch and retrieve resident demographic data in the computer system.
• Handle telephone inquiries about medical records and draft correspondence as necessary.
• Ensure signed checkout and return of medical records when accessed.
• File both active and inactive records according to policy.
• Maintain confidentiality of user password and protected health information, and promptly report any breaches.
• Report unauthorized access attempts of facility information systems.
• Perform assigned duties with administrative responsibility and accountability.

Committee and Personnel Functions

• Serve as secretary for facility committees as assigned.
• Prepare documentation and reports for committee reviews.
• Report any suspected fraud to administration.
• Ensure workstations are secured or locked when unattended per facility protocols.

Staff Development and Safety

• Participate in mandatory training including OSHA, TB, HIPAA, and abuse prevention.
• Attend approved workshops and seminars.
• Report unsafe or defective equipment immediately.

Equipment and Work Area Maintenance

• Report equipment issues promptly.
• Ensure supply replenishment and clean work areas before breaks and end of shift.

Additional Duties

• Report suspected fraud related to billing and cost reports.
• Accept other duties as assigned.

Qualifications

• High school diploma or GED required.
• Typing skills of at least 45 words per minute and familiarity with dictation equipment.
• Basic knowledge of medical terminology, anatomy, physiology, legal health information aspects, coding, and indexing preferred but not mandatory.
• Proficient in computer operations related to data entry and retrieval.
• Ability to read, write, speak, and comprehend English including technical documents.
• Mathematical skills to apply fractions, percentages, ratios, and proportions.
• Sound judgment and tactful communication skills.
• Ability to work well with others and follow instructions.
• Physical capability to move intermittently, lift up to 25 pounds to a height of 5 feet, and carry weights for distances up to 50 feet.
• Must meet facility health requirements including physical and medical exams.

Work Environment

The role involves working in office and facility areas with frequent movement and interruptions. May require working beyond normal hours including weekends and holidays, with potential call-backs during emergencies. Exposure risks include infectious diseases, hazardous chemicals, and interactions with emotionally disturbed individuals. Reasonable accommodations provided for disabilities.

Additional Information

Management reserves the right to revise job duties at any time. Statements herein represent typical duties but are not exhaustive. Equal employment opportunity is provided without discrimination based on legally protected status.