Medical Records Director

Position: MEDICAL RECORDS DIRECTOR
POSITION SUMMARY:

The Medical Records Director assumes authority, responsibility and accountability for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards and county, state and federal laws and regulations, as applicable, for long term care facilities. Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible and systematically organized.

REPORTING:

This position is responsible to the AdministratorFLSA STATUS:
Non-Exempt

ESSENTIAL JOB FUNCTIONS:

Perform health record maintenance duties; assembling, labeling, cleaning, filing and purging documents

Keys information into computer systems, including EMRMaintain stock of forms and record supplies

Request necessary resident information from transferring facilities

Process external information requests from authorized institutions and individuals

Compile statistical data at the direction of Administrator Prepare Alirts (OSHPD) yearly report

Maintain the confidentiality and physical security of health records in accordance with HIPPA rules and regulationSPerform concurrent and discharge quantitative audits of health records. Physician visit audits. Notification of physician when required by procedure

Develop and perform specialized audits on a predetermined time sequenced rotation with plan of completion to be defined and time limited. Audit all current resident charts to notate deficiencies and obtain and assist in corrections on a scheduled basis. Submit deficiency reports and to persons responsible for correction with date of completion to be returned (3 days) to the Administrator, Director of Nurses or designated representatives.

These audits will include but are not limited to:

Admission audits within 24 or 48 hours,7th 14th & 21st day Discharge Charts Skin and pressure soresWeights
- Weekly/Monthly Foley Catheter, Intake and OutputADL records

Diabetic

Lab/X-Ray Special Therapy, i.e., IV, PT, OT, Inhalation, Tube Feeders, etc.

Medicare Q shift Charting Psychotropic Current  H & PNursing Weekly Progress Notes Physician Visits Bowel and Bladder Plan of Care - entries of each discipline

Medications and Treatments Change in condition
- Daily Telephone Orders Quarterly Progress notes
- Activity, Dietary, Social Service, Discharge Planning.

MDS
- Initial, Quarterly, Yearly, Change in condition

Accidents/Incident Reports Intensity of Care Directives Disease index coding at time of admission, when diagnostic status alters and within 30 days of discharge date. Complete any outstanding disease index coding

Discharge charts must include the following information prior to filing:

Final Diagnosis and/or Death Certificate Completed Disease Index Coding Obtain all outstanding documentation and required signatures to meet criteria mandated by facility policy.

Mail telephone order forms to physicians daily, assure prompt return and file in chart

Prepare Physician Orders, Medication/Treatment records, ADL records and Resident Care Plans for accurate input into computer and printing on scheduled basis

Perform computer operation functions including regular input of data and printing on a scheduled basis

Keep computer terminal(s), keyboard(s) and office clean and functional

Maintain appropriate medical record storage and destruction of medical records consistent with facility policy

Follow-up on reports and recommendations submitted by the Medical Records Consultants and Service Center Medical Records Analysts Report to the Director of Nursing and Administrator significant documentation problems

Attend and participate in in-service education and staff meetings as required, including risk management and daily stand-up meetings. Maintain minutes of meetings/files as requested

Be courteous, considerate and cooperative when communication with all facility personnel, resident and public

React appropriately to emergencies and disaster situations

JOB FUNCTIONS:

Demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions

Appreciates the importance of maintaining confidentiality of resident and…