Medical Records

Bear Mountain Health Care • Worcester, MA • 51min ago

Work Schedule: Monday through Friday days, to include weekends and variable hours as needed

POSITION 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 information in computer; delivering records.

ESSENTIAL FUNCTIONS

· Gathers patient information by collecting demographic information from a variety of sources; interacting with admission, unit nurses and physicians' offices

· Maintains master patient index by completing assigned portion of daily audit trail; corrects and communicates problems according to established procedures.

· 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.

· Delivers charts to assigned areas of the facility by following established routing procedures.

· Keeps health care providers informed by communicating availability or unavailability of the record.

· Maintains quality results by following facility standards.

· Maintains continuity of work operations by documenting and communicating actions, irregularities, and continuing needs.

· Stores records appropriately by dating stored documents accordingly and keeping records of location.

· Properly maintains the medical records of residents and thins the record as needed per standards.

· Keeps medical records neatly organized for ease of document location per set standard.

· Maintains patient confidence by keeping patient records information confidential.

· Serves and protects the facilities community by adhering to professional standards, Paradigm policies and procedures, federal, state, and local requirements, and State DPH standards.

· Enhances medical records and facilities reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.

Skills/Qualifications: Time Management, Organization, Attention to Detail, Quality Focus, Professionalism, Productivity, Thoroughness, Coordination, Deadline-Oriented, Internal Communications, Reporting Skills

POSITION QUALIFICATIONS

Competency Statement(s)

Accurate - Ability to perform work accurately and thoroughly.

Communication, Oral - Ability to communicate effectively with others using the spoken word.

Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

Technical Aptitude - Ability to comprehend complex technical topics and specialized information.

Working Under Pressure - Ability to complete assigned tasks under stressful situations.

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