Hospice Medical Records

Office / Team Support

Assists the clinical department and program office with the clerical duties associated with all aspects of medical record keeping, chart audits, DME management, aide scheduling and office support.

• Maintains and updates patient admission files in PAS.
• Completes admission audit and communicates issues/problems to the Clinical Director.
• Inputs updates into current software system any information or changes relating to insurance, level of care, staff assignment and/or discharge.
• Scans and files all paper clinical data, hand signed orders and consents into patient records.
• Ensures plan of care/comprehensive assessment update/recertification are opened in a timely manner to allow staff to document their summaries prior to team.
• Ensures plan of care/comprehensive assessment update/recertification are resolved once approved by Clinical Director or designee.
• Tracks and emails as appropriate certification/recertification statements/POC/CA and all orders.
• Runs unresolved orders report weekly to track unsigned orders.
• Maintains patient on-call book.
• Contacts physician office, hospital or nursing facility in a timely manner in order to obtain current information, signatures or any other information pertinent to the patient's admission and their hospice chart.
• Assists as needed with providing information necessary for annual report and other patient data which may be requested.
• Receives visit logs from all staff.
• Inputs all visit logs of staff not electronically documenting into current software system and compares visit logs to contact visit reports weekly.
• Tracks and ordering durable medical equipment (DME) and medical supplies.
• If requested, participates in team meeting and is responsible for ensuring all documentation and electronic records are present as requested at team meeting.
• Responsible to maintain the team meeting sign-in sheet, and ensures that the team agenda is attached.
• Responsible for closing clinical/bereavement charts, and preparing charts beyond thirteen (13) months so that they may be moved to off-site storage.
• Communicates with the Clinical Director in order that the charts are sent to off-site storage.

• High school graduate or equivalent.
• One (1) year medical records experience, preferably in home health or similar operation.
• Electronic medical record experience preferred.
• Positive interpersonal skills and good organizational skills.
• Good computer skills.
• Is flexible, cooperative and self-directed in fulfilling roles.
• Ability to function as a member of an integrated healthcare work team.