Medical Records Assistant

Job Title: Medical Records Assistant
Classification: Non-Exempt
Department: Medical Records / Nursing Administration
Reports To: Director of Nursing / Designee
Location: Robison Health & Rehab Center – Portland, Oregon

The Medical Records Assistant is responsible for providing administrative and clerical support to the Medical Records department to ensure resident medical records are accurate, complete, organized, and maintained in compliance with facility policies and applicable state and federal regulations.

This position primarily focuses on scanning, uploading, filing, tracking, and organizing resident documentation within the facility's electronic health record (EHR) system, Point Click Care  (PCC). The Medical Records Assistant supports daily documentation audits, identifies missing records, and assists with maintaining survey readiness.

This position does not require an LPN or RN license. The ideal candidate will possess strong organizational skills, attention to detail, computer proficiency, and the ability to maintain confidentiality when handling sensitive resident information.

1. Medical Records Management

• Scan, upload, index, and organize resident medical documentation into Point Click Care  (PCC).

• Ensure documents are accurately uploaded to the appropriate resident chart and designated section.

• Maintain complete, organized, and accessible electronic medical records.

• Assist with processing admission, transfer, discharge, and other resident-related documentation.

• Review documents for completeness, legibility, and appropriate identification before scanning.

• Maintain an organized workflow to prevent backlogs in medical record processing.

2. Scanning and Documentation

• Scan and upload required resident documents, including but not limited to:

  • Preadmission Screening and Resident Review (PASRR) documentation.

  • Hospice records and related documentation.

  • Dental records and consultation reports.

  • Admission packets and signed admission documents.

  • Hospital discharge summaries and transfer paperwork.

  • Physician orders and other clinical documents as directed.

  • Outside provider records and consultation documentation.

• Ensure documents are filed promptly and accurately.

• Identify missing, incomplete, or incorrectly filed documents and notify the appropriate department.

• Assist with reducing outstanding scanning and documentation backlogs.

3. Medical Records Auditing and Compliance

• Assist with daily medical record audits using facility-established checklists and procedures.

• Verify that required documents are present in resident charts.

• Maintain tracking logs for missing documentation and outstanding records.

• Follow up with appropriate departments regarding missing or incomplete paperwork.

• Support preparation for state surveys, regulatory inspections, and internal audits.

• Report documentation discrepancies to the Medical Records Coordinator, Director of Nursing, or designated supervisor.

• Assist with implementing corrective actions related to medical record organization and documentation completeness.

4. Administrative and Departmental Support

• Organize incoming medical records, correspondence, and documentation requests.

• Maintain filing systems, scanning logs, and documentation tracking tools.

• Communicate with nursing, admissions, social services, and other departments to obtain missing records.

• Assist with retrieving medical records for authorized staff and approved requests.

• Support the Medical Records department with additional clerical responsibilities as assigned.

• Prioritize daily scanning, auditing, and documentation tasks according to department needs.

5. Confidentiality and Regulatory Compliance

• Maintain strict confidentiality of resident medical information in accordance with HIPAA and applicable privacy laws.

• Follow facility policies regarding the handling, storage, transmission, and disposal of confidential records.

• Access resident information only as necessary to perform assigned job duties.

• Immediately report potential documentation errors, privacy concerns, or compliance issues to the appropriate supervisor.

• Maintain professional standards when communicating with residents, families, staff, and outside providers.

Education

• High school diploma or GED required.

• Additional education or certification in medical records, health information management, or healthcare administration preferred but not required.

Experience

• Previous…