POSITION DESCRIPTION:
Assists in developing and maintaining an appropriate health record service and system for the center.
QUALIFICATIONS:
High School diploma. Strong written and verbal skills in English necessary for business. Administrative and organizational ability. Knowledge of medical terminology. Previous experience in a skilled nursing home health care setting. Prior health record experience preferred. Basic computer experience preferred. GENERAL DUTIES AND RESPONSIBILITIES
ADMINISTRATIVEMaintains Health Record System according to Federal, State and Community requirements. Participates in assigned meetings and inservices. TECHNICALInitiates Resident Health Record. Initiates and maintains logs and indices as required: Admission/Discharge Register Master Patient Index Disease Index Medicare Log (if applicable) Audit System Discharge Control LogChart Removal LogResident Care Plan LogTelephone Audit LogPerforms Audits AdmissionsDischargeRoutine Quality Assurance Audits Special as required Coordinates Physician Documentation Telephone Orders History and Physicals Monthly Physicians Orders Physicians’ Progress Notes Certifications and Recertifications Discharge Summaries Thins charts and maintains overflow files as required. Records and maintains minutes of meetings as assigned. Inputs and prints computerized medical records forms. Prepares statistical reports as required. Destroys old health records as required. Assembles, analyzes and completes discharge records. Maintains unit filing system. CONSUMER SERVICEPresents professional image to consumers through dress, behavior and speech. Adheres to Company standards for resolving consumer concerns. Ensures that all consumer/resident rights are protected.
