Summary:
Under the supervision of the Director Health Information Services (HIS) retrieve assemble scan and analyze inpatient and outpatient medical records. Perform a wide variety of analytical clerical data entry data collection retrieval and filing duties. Work in accordance with hospital policy and TJC guidelines. Interact closely with medical staff.
Responsibilities:
Retrieve paper medical records for patient care areas including Access Center inpatient and partial hospital units and deliver them as required to support care delivery.
Retrieve paper records of all discharged inpatients and partial hospital patients within 1 business day of discharge. Update the HIS tracking log with discharges and retrieval information. Follow up on missing or late documents or charts. Report to HIS Director.
Prepare and scan paper records into Epic Lifechart system according to department policy and procedure. Review 100% of scanned documents for accuracy legibility and presence.
Review both quantitatively and qualitatively the entire medical record of discharged patients including electronic portions checking for completeness and accuracy to assure that each medical record is complete according to Hospital policy. Record chart deficiencies in the Hospital deficiency system.
Answer telephone and receive customers responding to routine questions and requests referring other requests to appropriate personnel or records message.
Retrieve paper records for physicians other hospital departments and personnel. Determine the legitimacy of the request and the requestor to ensure patient confidentiality.
Scanloose material in records of patients who have been discharged. Review for and obtain signatures and countersignatures on notes as needed.
Purge and scanactive records in long term programs regularly in accordance with department procedure.
Update deficiency system as records are completed.
Prepare scanned records for shredding once quality review has been completed. Contact shredding company as necessary.
Monitor space in archival file room. Purge records according to the scheduleand prepare for offsite storage.
Perform other clerical duties as assigned.
Other information:
BASIC KNOWLEDGE:
High school graduate or equivalent. Knowledge of medical/psychiatric terminology preferred.
Organizational skills to gather assemble and maintain data from a wide variety of sources.
Solid computer skills and the ability to operate standard and automated office equipment
EXPERIENCE:
1-2 years of progressively more responsible job-related experience in a Health Information Dept other hospital department or medical office.Previous data entry and clerical experience in healthcare preferred.
Previous electronic medical record experience a plus.
SUPERVISION RESPONSIBILITY:
None.
Medical Records Clerk • East Providence, Rhode Island, United States
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