Medical Records

SUMMARY: Creates new medical records and retrieves existing medical records by gathering appropriate record folders and contents; assigning and recording new record numbers; verifying existing record numbers; inputting and recording locations to computer; delivering records.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Gathers patient information by collecting demographic information from a variety of sources; interacting with registration areas and physicians' offices; retrieving information from automated printer.
• Initiates the medical record by creating and processing the patient care record folder.
• Maintains record availability by processing charts into the department; using chart mark-off procedures; facilitating chart location activities.
• Retrieves medical records by following chart-out procedures; documenting reasons charts cannot be retrieved for statistical and follow-up purposes.
• Keeps health care providers informed by communicating availability or unavailability of the record.
• Communicates with the attending health care providers in a timely manner
• Maintains quality results by following facility standards.
• Maintains continuity of work operations by documenting and communicating actions, irregularities, and continuing needs.
• Maintains patient confidence by keeping patient records information confidential.
• Serves and protects the hospital community by adhering to professional standards, hospital policies and procedures, federal, state, and local requirements, and JHACO standards.
• Enhances medical records and facility reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
• Maintains transportation schedules and records to ensure patients arrive to scheduled appointments.
• Other duties as assigned.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill, and/or ability required.

• High School Diploma or Equivalent required.
• Long Term Care Experience preferred.
• Ability to read, write, speak and understand the English language.

PHYSICAL DEMANDS: The physical demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Required to sit, stand, bend and walk regularly; lift and/or move up to 25 pounds.
• Visual and auditory ability sufficient for written and verbal communication.
• The noise level in the work environment is usually moderate.