Location: all cities,TX, USA
Job Purpose:
To maintain residents medical records in accordance with facility policies and regulations.
Essential job Duties and Responsibilities:
Medical Records Functions:
Verify appropriate resident information is entered in the census register. Initiate the active medical record and in-house thinned file, prepare labels, etc. Complete or verify admission checklists and admission audits (if applicable).
Conduct concurrent audits/quality monitoring at regular scheduled intervals. Thin in-house records in accordance with the written guidelines and file in discharge chart order. Audit the thinned records for deficiencies using audit forms. Contact physicians or departments when deficiencies are noted.
Maintain a monitoring system to assure telephone orders and other information is signed or completed by the physician as needed. File all incoming medical information in the current record. Monitor timeliness of Physician/Nurse Practitioner on a monthly basis.
Initiate Discharge Summary Process. Assemble medical records from the nursing station and the thinned file and establish in discharge order.
Verify the retrieval of all medical information from various locations, i.e. ADLs, MARs, TARs, etc. Audit the discharge record for deficiencies utilizing a discharge audit checklist. Contact physician or departments as needed to complete discharge audit deficiencies. Follow up and monitor the process for completing the discharge audit deficiencies; complete within 20 working days. Maintain discharge record in an incomplete record area until complete. File completed discharge record in discharge record section of record department.
Retrieve information from files as requested. Transmit documents as requested by fax, email or other means of transmission. Document all items removed from client files, including information about who received the items, the date and time received, and the date and time the items were returned to the file. Observe HIPPA guideline carefully, and maintain current knowledge of best practices with regard to client/patient privacy issues.
Meeting Management:
Attend orientation and in-service as required by the state. Participate in Company committees when
requested.
Resident Rights:
Understand, comply with and promote all rules regarding Residents rights.
Other Job Functions:
Staff Development:
Participate in in-service training, assist in implementing orientation programs and job skills training, maintains professional competence
Stand In Function:
Fills in as Nurse (if licensed) or CNA, or other nursing positions for which qualified, as needed.
Other Duties:
Other duties as assigned
Physical and Sensory Requirements (with or without the aid of mechanical device):
Works in a climate-controlled and well-lighted environment.. Works in an office and throughout the building daily. Has Category 1 risk of exposure to infectious diseases, but receives training in handwashing practices and Universal Precautions and has access to personal protective equipment if direct exposure is anticipated. Is subject to interruptions, noise, and odors daily
Walking, reaching, climbing, bending, lifting, grasping, fine hand coordination, pushing and pulling, ability to distinguish smells, tastes and temperatures, ability to communicate with residents and employees, ability to understand and follow training, ability to instruct staff in service education, and the ability to remain calm under stress.
Qualifications:
Must have training and certification or experience as required by the State.
Must have ability to read, write and follow oral and written directions at a level necessary to accomplish the job.
Must be able to relate positively and favorably to residents, families, and government regulators, and to work cooperatively with other associates.
Must be capable of maintaining regular attendance.
Must be capable of performing the Essential Job Functions of this job, with or without reasonable accommodation.
Related administrative experience and/or experience as CNA or Nurse at a level necessary to accomplish the job.
At Will Statement:
This job description provides guidelines only and none of its provisions are contractual in nature. The Job Description does not guarantee employment for any specific period of time or any specific terms or benefits of employment. All employment with the Company is at will, meaning that you or the Company may terminate the employment relationship at any time, with or without notice or cause. No member of the Companys management staff has the authority to make oral or written promises of employment that are inconsistent with the policy of at-will employment. The at-will nature of employment may only be modified through a written employment agreement signed by the head of
the Companys governing body and the team member.
Health Insurance Portability and Accountability Act (HIPAA):
Our Facility is committed to protecting the privacy, security and integrity of individually identifiable health information received from or on behalf of our employees. The Facility adheres to the highest standards of integrity in the performance of its business and is prepared to maintain compliance with
HIPPA and other regulatory requirements by adopting and adjusting policies and processes as necessary. All employees are required to adhere to all HIPPA regulations