Performs medical records activities including filing, pulling and delivering medical records to the proper location and handling the information in a confidential manner. Maintains and makes available to authorized users timely, accurate, secure and complete patient health information. Controls the release of medical information in accordance with applicable standards.
Duties and Responsibilities
Models Prime Care’s mission, philosophy and values.
Pulls charts for appointments and all requests for charts.
Reviews all returned medical records for completeness and assures that each provider has initialed, dated and signed all paper work before being filed.
Sorts, maintains and files information, correspondence, labs and tests into charts within 24 hours following established chart organization.
Answers telephone calls and requests pertaining to medical records.
Identification of the Medical Record by the following:
- First and Last Name on the Chart and all progress notes.
- DOB on chart and on all progress notes.
- Allergy stamp on the front of the chart and if no allergy written NKA and if there is an allergy it needs to be written on all progress notes and on the front of the chart.
- Yearly sticker placed on the side of the chart next to the patient’s name.
- Yellow sticker on the front of all Diabetic charts.
- Orange stickers on the front of all prenatal charts.
- PCP on the bottom L hand corner of all charts.
Assures that the amount of information in the medical record is manageable and relevant.
Adheres to established timelines to ensure that documents such as labs and x-rays are filed within 24 hours.
Makes sure that all charts follow the chart set-up, currently draft #7 and that those that do not are addressed in a timely manner.
Ensures those assigned to that department are directed in such a manner as to prioritize properly to get the most important tasks done:
a. File lab within 24 hours.
b. All charts filed at the end of the day.
Acknowledgement of all HIPPA regulations before a patient’s medical information is disclosed and there must be a signed consent by the patient.
Procedure for chart checking is as follows:
- MMRC first checks the demographics.
- Checks for consent for treatment –updated yearly.
- Checks that HIPPA is updated yearly.
- Makes sure that all forms are signed and dated by the front end staff and the patient.
- Check the last note for the MA and provider signature.
- If the patient missed an appointment—progress note should be stamped” NO Show”.
- Once chart is checked, any loose papers with a provider signature such as labs, x-rays, and referrals should be filed and placed by date in the chart.
- Provider gives abnormal labs to MRC to pull chart and place on his/her desk for review.
- MRC will have a list of all prenatal with due dates .She will responsible for sending all their records including history, progress notes, labs and ultrasound reports pertaining to the prenatal care to via fax to St. Mary’s Labor and Delivery Dept. during the 36-38 weeks or after the GBBS result is in, and give a copy of the faxed material to the physician after faxing.
- When Medical Records are requested always have a medical release signed by the patient or the patient’s guardian –requests are good for 1 year or otherwise specified, for patient’s that are applying for Social Security Disability. A signed release by the patient will be sent. Once received by and signed off by the provider, the MRC will send copies of our records by mail. When lawyers are requesting copies of record, there is a $25.00 charge and once payment is received and the provider signs off the request MRC will send copies of the records by mail.
- Sending records from one physician to another by patient request for transfer of care, there is no charge and MRC will mail a copy to the physician.
- Under No Circumstances will the MRC send HIV records unless specified by the patient.
- For Mental Health Records, these records are accessible by the mental health supervisor and require a special release form.
1. Must be able to remain in a stationary position 50% of the time.
2. Must be able to move around the clinic site 50% of the time.
3. Constantly operates a computer, computer printer, copy machine, and telephone.
4. Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
5. Must be able to transport from one site to another.
6. Must be able to cover other shifts as necessary.
Required Knowledge, Experience, or Licensure/Registration
High School diploma
Two years previous medical office experience (preferred)
Bilingual (English/Spanish) preferred
Good communication and interpersonal skills
Strong customer service skills