Is responsible for analyzing the contents of the medical record to insure internal consistency and completeness, abstracting administrative and clinical data from the medical record which is used to comprise the hospital’s discharge statistics, disease, operations, and physician indices. Is responsible for assisting physicians and other hospital personnel with medical record request.A.
Assembles the medical record of each discharged patient according to the “Order of the Medical Record”. Researches all admissions and combines for unit record; verifies unit number and notifies other departments of updates. Corrects in all systems applies correct number labels to all volumes including year label. Reconciles demographic and administrative data as indicated on the computer against the information on the medical record and maintenance any changes. Notifies admissions of corrections. (E)B.
Performs the quantitative analysis of medical records by checking each discharge record for incomplete items and noting these on the Medical Record Deficiency Checklist for the attending physician, other staff physicians, residents or ancillary professional departments as required in order to obtain a completed record. Files into the complete or incomplete record file as indicated. (E)C.
Abstracts data and services by clinical category each medical record by assigning a service to each record based on final diagnosis and operations under the specialties and subspecialties of Medical Staff. Assigns the representative code number for the clinical service and enters in computer. (E)D.
Maintains par level of office supplies and notifies supervisor when supplies are needed. (E)E.
Assists physicians in locating their outstanding records. Rechecks all records worked on by physicians and deletes form physicians’ incomplete listing when completed. Removes tags from all signed documents as record is rechecked. (E)F.
Assists physicians, patients and others with release of information requests, both in person and over telephone; abides by confidentiality policies consistent with State and Federal requirements. Responds to requests for patients’ records from nursing units. Locates patients’ records and enter party to whom record will be sent, patient name, and record number on the computers’ location system. When records return, remove form locator system, (MLOH). (E)G.
Answers the telephone on a rotating basis with other department personnel. (E)H.
Performs other duties as requested by the Medical Record Director or Medical Record SupervisorI.
Demonstrates competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of members served by the department. (E)J.
Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age specific and other developmental needs of each member served. (E)K.
Takes personal responsibility to ensure compliance
with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities.L.
Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.M.
Demonstrates adherence to the CORE values of Santa Rosa Health Care. (E)N.
Performs other duties as assigned. (M)