Responsible for assembling, analyzing, and maintaining medical records according to established procedure.
High School graduate or equivalent with GED
- Health Information Management Certificate, HIT PRO Certificate preferred
- Two years office experience, preferably in a medical setting
- Excellent organization and communication skills
- Strong Computer skills with ability to type 40 wpm
- Ability to navigate EHR and document management systems
- Knowledge of medical record format and content for all programs
- Ability to identify nonstandard forms and determine appropriate action required
- Detail oriented
- Ability to review record and verify patient identification
- Ability to perform job function and make decisions without direct supervision
- Ability to lift and move/transport multiple charts
- Ability to bend and reach overhead
- Valid driver's license and automobile insurance as per policy
- Satisfactorily complete competency requirements for this position.
Responsibilities of all employees:
- Represent the Company professionally at all times through care delivered and/or services provided to all clients.
- Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
- Comply with Company policies, procedures and standard practices.
- Observe the Company's health, safety and security practices.
- Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
- Use resources in a fiscally responsible manner.
- Promote the Company through participation in community and professional organizations.
- Participate proactively in improving performance at the organizational, departmental and individual levels.
- Improve own professional knowledge and skill level.
- Advance electronic media skills.
- Support Company research and educational activities.
- Share expertise with co-workers both formally and informally.
- Participate in Quality Assessment Performance Improvement activities as appropriate for the position.
- Confirm patient name, medical record number, team and program are on every page in the record, front and back
- Identify and tape torn edges
- Mount and tape down any sheets less than 8.5 by 11 inches on an 8.5 by 11 inch sheet
- Remove all staples
- For any documents on card stock or manila make a photocopy before scanning
- Perform daily maintenance of the scanner
- Calibrate the scanner for proper image quality as needed
- Monitor the manual indexing queue of unassigned images
- Prioritize batches received in the e-fax queue and retrieve for processing and uploading into the EMR
- Review each electronic image within the batch. Compare with hard copy to confirm image quality, appropriate order and appropriate rotation of image
- Determine the correct patient name, medical record number, program, document type or section (if appropriate).
- Index the image appropriately by required patient data elements according to facility specific guidelines and naming conventions.
- Maintain and reconcile the death/discharge report to ensure that all closed files are accounted for prior to scanning.
- Maintain production log that outlines database names, scan dates and CD burn dates.
- Maintain database (i.e., naming conventions, database size and folder profile).
- Perform scanning functions while maintaining a satisfactory level of productivity.
- Index scanned documents according to a predetermined file layout while maintaining a satisfactory level of accuracy.
- Ensure daily system back-up.
- Perform quality review of scanned documents prior to burning to CD.
- Communicate with department supervisor regarding any adverse software or hardware issues.
- Protect the confidentiality of the scanned and paper documents at all times.
Scanning Quality Control
- Review each image in the batch and verify the following
- Correct patient name and program level
- Proper indexing level / naming convention
- Image quality (readable, orientation, multiple sides, etc.)
- For each page scanned or indexed with errors
- Rearrange out of order images within the electronic document
- Relocate electronic images that are incorrectly filed in another document
- Replace electronic images that have unacceptable image quality or have been updated
- Modify the indexing as appropriate
- Process admission paperwork including chart assembly
- Request prior medical records from hospitals and physicians as indicated on the Nursing History and Physical and Team Daily Report
- Files/Scans medical record documentation in a timely manner making certain that the patient name and number correlate to the chart
- Pulls and prepares charts for IDG/IDT meetings. Ensures that filing and scanning are current
- Pulls charts for audits, research and other legitimate requests
- Audits charts following the death/discharge of the patient. Identify delinquent documentation that is needed for chart completion
- Prepares and updates the chart deficiency report weekly and distributes to the Clinical Manager, Regional Director, and HIM Supervisor for resolution
- Monitors the return of all documentation until the chart is complete and escalates any chart deficiencies that have not been resolved as necessary
- Daily opening, logging and sorting of mail, work queues and IDG/IDT paperwork
- Maintains patient confidentiality at all times
- Performs other job-related duties as requested.*