MEDICAL RECORDS DESIGNEE
MEDICAL RECORDS DESIGNEE
PURPOSE OF YOUR JOB POSITION
The primary purpose of your job position as a MEDICAL RECORDS DESIGNEE is to maintain medical records in accordance with federal and state guidelines, as well as established policies and procedures, to insure a complete medical records program.
MAJOR DUTIES AND RESPONSIBILITIES
Listed below is an outline of the duties and responsibilities that you will be required to perform.
In general, the MEDICAL RECORDS DESIGNEE is charged with the responsibilities of processingresident charts – collects, assembles, checks for completion, files, and the general safekeeping of the resident’s medical records.
Although your job description is broad, every effort has been made to make this outline ascomplete as possible.
- Organize, plan, and direct the medical records program in accordance with established policies and procedures
- Maintain various registries/indexes as required by governmental agencies as well as administrative policies
- Perform medical diagnosis coding of resident diagnoses and/or disease conditions as warranted
- Collect records, assemble in proper order, and analyze them for appropriate completion
- Monitor incomplete records for timely and appropriate completion prior to discharge filing
- File records and other information as directed
- Obtain ‘overflow’ records from nursing station and file in the resident’s in-house files
- Audit nursing station records for appropriate data and timely completion of specific resident information
- Retrieve charts for examination by physicians or other authorized persons who present a written authorization by the resident or attending physician
- Safeguard records from unauthorized access or disclosure except when subpoenaed by court order
- Abstract information from charts when authorized for insurance companies or other third party
- Maintain various files necessary to update required medical data on residents in order to meet funding agency regulations (i.e. Utilization Review and Medical Information Forms)
- Retrieve and re-file records for physicians and other authorized personnel
- Retrieve records for medical care studies, abstract information for statistical studies, and tabulate data for review by committees as directed by supervisor
- Perform clerical duties for committees of the facility as directed by the supervisor
- Maintain confidentiality of all pertinent resident care information to assure resident rights are protected
- Attend and participate in workshops, seminars, etc. as approved
- Perform miscellaneous duties pertaining to medical records and may assist office personnel in business office department under direction of supervisor
- Other duties as assigned by supervisor or consultant
- Sitting, standing, bending, lifting, and moving intermittently during working hours
- Works in well-lighted/ventilated office areas of the facility
- Subject to frequent interruptions
- Willingness to work beyond normal working hours and in other positions temporarily, when necessary
- Communicates with medical staff and other supervisory personnel
- This facility will make reasonable accommodations that will permit an employee to perform the essential functions of his or her position
Lake Park Nursing and Rehabilitation Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Lake Park Nursing and Rehabilitation Center complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Lake Park Nursing and Rehabilitation Center expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of Lake Park Nursing and Rehabilitation Center’s employees to perform their job duties may result in discipline up to and including discharge.