OSITION DESCRIPTION

Assists in developing and maintaining an appropriate health record service and system for the center.

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 skilled nursing home health care setting. Prior health record experience preferred. Basic computer experience preferred.

GENERAL DUTIES AND RESPONSIBILITIES

ADMINISTRATIVE Maintains Health Record System according to Federal, State and Community requirements. Participates in assigned meetings and inservices.

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) 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. Records and maintains minutes of meetings as assigned. Inputs and prints computerized medical records forms. Prepares statistical reports as required. Destroys old health records as required. Assembles, analyzes and completes discharge records. Maintains unit filing system.

CONSUMER SERVICE

Presents professional image to consumers through dress, behavior and speech. Adheres to Company standards for resolving consumer concerns. Ensures that all consumer/resident rights are protected.