Medical Records Assistant
Job Description
Job Description
Health Record Assistant assists in developing and maintaining an appropriate health record service and system for the center.
Health Record Assistant 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 health care setting.
• Prior health record experience preferred.
• Supervisory experience preferred.
• Basic computer experience preferred.
Health Record Assistant GENERAL DUTIES AND RESPONSIBILITIES:
ADMINISTRATIVE
• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and in-services.
Health Record Assistant SUPERVISION (if applicable)
• Meets unit work goals through assignment of staff to resident care needs.
• Monitors staff performance through coaching, praises and recognizes effective performance or takes
direct corrective action after coaching (counseling) as needed.
Health Record Assistant TECHNICAL
• Initiates Resident Health Record.
• Initiates and maintains logs and indices as required:
• Admission/Discharge Register
• Master Patient Index
• Disease Index
• Medicare Log (if applicable)
Job Descriptions Manual
Health Record Assistant (Note: also may be referred to as Health Records Director or Medical Records Director in Health Records Manual.)
Administrator
• Audit System
• Discharge Control Log
• Chart Removal Log
• Resident Care Plan Log
• Telephone Audit Log
• Performs Audits
• Admissions
• Discharge
• Routine 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.
• Maintains and controls release of information within State, Federal and HIPPA regulations:
• Subpoena in conjunction with Senior Vice President of Clinical Compliance
• Correspondence – including legal
• Access to Records
• Records and maintains minutes of meetings as assigned.
• Inputs and prints computerized medical records forms.
• Prepares statistical reports as required.