Position
Medical Records Clerk (SNF)
Department
Medical Records
Reports To
Director of Medical Records
Prepared By
Human Resources
Prepare Date
December 2010
Under the direct supervision of the Director of Medical Records, the Medical Records Clerk is responsible for the planning, organizing, management and control of medical record services to ensure that records are completed timely and accurately and to be the source of health information by maintaining complete and accurate records compiled during the resident’s stay at the Skilled Nursing Facility.
Demonstrates the competencies to fulfill the Mission and values of St. John of God Ministry, which are the foundation of all activities performed by every employee
We are here to extend the healing mission of Jesus through the Hospitality of St. John of God by continually improving the health and quality of life of the people we serve
Hospitality
Creates an environment where people can feel welcomed, comfortable, understood, esteemed and loves
Respect
Recognizes the richness of God’s gifts and His presences in every person
regardless of age, situation in life, culture or religion
Quality
Works toward creating centers of excellence and service fostering continuous improvement in the quality of service
Responsibility
Encourages cooperation as a way of promoting standards of competence, efficiency and accountability as we carry out our duties in the Mission
*SKILLED NURSING EXPERIENCED HIGHLY REQUIRED*
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Follows current policies, procedures, and job descriptions for the Medical Records Department
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Participates in meetings such as safety trainings, staff meetings, etc.
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Quality Monitoring and Quality Assurance Functions: Participates in QA committee and process
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Audits – Quantitative/qualitative and process
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Conducts routine monitoring: admission, discharge, MDS, quality indicators and survey issues
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Maintains systems for filing, retention, and destruction of overflow records and discharged records
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Manages and processes release of information requests, and assures that the process meets the legal standard of the facility’s policy and standards
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Understands all aspects of the Point Click Care computer system, provides input into decisions related to the PCC system (planning and future expansion)
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Maintains forms for Medical Records and Nursing, e.g., forms management system for development, review, reproduction of facility forms, maintains a master forms manual
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Completes data entry functions
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Admission:
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Maintains and completes appropriate information in the current census register on admission Initiates the in-house overflow file, prepare labels, etc.
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Completes admission checklists and admission monitors
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Completes coding of admission diagnoses
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Resident’s Stay:
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Conducts regular monitoring/audits as scheduled
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Codes diagnoses as scheduled
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Thins in-house records in accordance to the facility’s policies and procedures
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Contacts physicians or department as needed when signatures or information are needed
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Files all incoming clinical information in the in-house records on a daily basis
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Monitors physician’s monthly visits
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Discharge:
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Maintains and updates discharge information
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Records discharge information in the census list
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Obtains clinical record from nursing station within 24 hours of the discharge or death of a resident
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Assembles discharge record from nursing station and overflow file in established discharge order
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Audits discharge record for deficiencies with the responsible persons/departments
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Other:
Orders and maintains Medical Records and Nursing forms and office supplies
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Performs other duties as assigned
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Follows organizational and departmental procedures
Information Management
Treats all information and data within the scope of the position with confidentiality and security
Risk Management
Cooperates fully in all risk management activities and investigations
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Sitting at least 40% of the time (shift)
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Standing at least 40% of the time (shift)
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Walking at least 20% of the time (shift)
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Lifting, pulling and pushing up to 50lbs on occasion
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Lifting, pulling and pushing between 10-20lbs multiple times daily
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Must follow the dress code policy
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Able to file quickly and efficiently constantly, included in filing is sorting, organizing, removing staples as needed, stapling, scanning, copying, collating, and folding
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Knowledge in medical terminology
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Experience with ICD-10 coding system or latest version
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At least 2 years of experience in Medical Records
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High school diploma or equivalent
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Knowledge of documentations and legal issues
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Understanding of payments systems in long term care
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Must keep all required certificates and/or licenses current
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Knowledge in medical terminology
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Basic MS Office (Word, Excel, etc.) and other computer skills, e.g., typing/data entry, creating forms, etc.
