Medical Records

JOB TITLE

MEDICAL

RECORD MANAGER DEPARTMENT

Nursing

SUPERVISOR

Director of Nursing

DUTIES AND RESPONSIBILITIES

Responsible and accountable for the record keeping procedures and storage of all medical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long term care facilities.

QUALIFICATIONS

High school diploma or equivalent required. Licensed Practice Nurse preferred with current active license in the state. Has a working knowledge of medical terminology and is proficient in the use of personal computer. Strong organizational skills needed as well as ability to communicate clearly and professionally both verbally and in writing.

CONTINUING EDUCATION

Encouraged and required if necessary to meet state regulations

EXPERIENCE

Long term care experience as a LPN preferred.

PHYSICAL DEMANDS AND ENVIRONMENT

Working in office and with residents in the facility, may be required to sit, bend, stoop, use keyboard. May occasionally be required to lift objects of 10 to 25 lbs. May occasionally be required to form task of staff LPN if licensed. Visits to other health-care facilities and offices may be necessary.

FUNCTIONS

Prepares charts for new admissions. Orders, maintains and distributes medical records forms. Monitor procedures to ensure confidentiality of patient information and guard against loss or destruction of data. Review admission information for accuracy and completeness Organize medical records into established order for permanent filing. Note deficiencies to be completed by physician and professional staff. Maintain follow-up of records with deficiencies until the record is complete. Upon discharge, assemble and review medical record for completeness. Ensure receipt of records of residents discharged from facility. Responsible for implementing discharge summaries with physician and staff. File medical records of discharge residents according to established policies. Maintain a documented, organized system readily accessible for authorized staff. Prepare reports and/or audits according to facility policy and as needed. Maintain confidentiality at all times. All of the previous information is intended to describe the general nature and level of work being performed and are not intended to be a complete list of all responsibilities, duties and skill required.

SAFETY SENSITIVE POSITION

This position involves working with confidential information, such as drafting residents' medical records, reviewing medical records for accuracy and completeness and maintaining the confidentiality of them at all time. A lapse of attention could result in the disclosure of confidential information or other injury.

Job Type:

Full-time Benefits:

Dental insurance Health insurance Life insurance Paid time off Vision insurance

Experience:

Medical records: 1 year (Preferred)

License/Certification:

LPN (Required)

Work Location:

In person