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|Clerk Medical Records|
|Facility:||Holy Family Hospital||Shift:|
|Department:||HFH Medical Records||Hours:||Part-time, 33 hrs/wk, Day/Evening Shift, 10:00am-6:30pm|
Job Summary: To collect, maintain, store, and make available to authorized users timely, accurate, and complete patient health information. Reviews and processes all patient records for completeness in compliance with JCAHO, State and CMS requirements. Organizes, prioritizes, locates, pulls, assembles, scans, indexes, quality checks, tracks both electronic and paper records, and sees to the appropriate transport of records requested by other departments in accordance with established standards. Fills in other HIM areas when needed.
Qualifications: At least 2 years experience working in a hospital medical record department working in a hybrid or electronic record environment required and/or equivalent recent college degree in health information from a two year accredited education program to include: discharge analysis and processing knowledge of JCAHO, State, HIPAA and CMS documentation requirements, physician suspension process, MPI, as well as other areas of HIM. Exceptional organizational and time management skills with ability to work in a fast-paced, productivity oriented environment required. Strong attention to detail. Excellent customer service, interpersonal/communication skills required. Proficient with computer programs: Microsoft Office and Outlook. Experience using Meditech preferred.
· Collects all current and previous medical records of discharged patients from Nursing units within 24 hours of discharge daily; weekend discharged charts are processed Mondays, unless OT has been approved.
· Collects loose filing for those discharged patient charts and inserts such filing in proper chart, maintaining a 98% accuracy rate.
· Combines current patient chart with any previous patient discharges for a unit record.
· Assembles discharged patient visits in appropriate chart order. Inter-files all late-arriving reports & paperwork into the correct chart order both electronically and on paper; assembles, scans, indexes, quality checks discharges daily.
· Retrieves and delivers medical records to nursing units and/or Emergency Department in a prompt and professional manner. Routine requests delivered within 20 min.; STAT requests within 5 min. as needed.
· Analyzes/audits medical records of discharged patients for completeness and accuracy according to departmental and hospital policy and procedures and regulatory agencies.
· Assists in providing excellent customer service, answering the telephone, handling customer requests and concerns, and taking accurate messages daily within a timeframe consistent with the urgency of the request.
· Responds to all routine fax requests within 24 hours of receipt. Weekend faxes outside of operational hours will be processed first thing Monday.
· Photocopies, scans, indexes and archives medical records as appropriate for other areas within department as necessary (auditing, ROI, etc....).
· Retrieves medical records upon request for clinical review, audits, and assigned 'pull' lists according to policy and procedure.
· Reviews, researches missing information and interfiles all loose reports into appropriate chart for each discharge day located in inpatient staging area and processing; notifies Supervisor and Director of all missing charts within 3 days and may be asked to report missing visits in RL.
· Refers any potential medical/legal issues to the Supervisor, Director and Risk Management in a timely manner if necessary.
· Must be familiar with all charting requirements.
· Verifies that all appropriate outpatient records are received in HIM from the department providing the service by reconciling the appropriate reports (sdc, woc, medcl, ed,etc...) with the days visits and notes status (Inpt, OBS, unavailable, missing). Ensures all visits are accounted for.
· Signs out (logs in) all visits being analyzed in Meditech and returns (logs out) all visits upon completion. Returns & files charts in appropriate location (Inpt,stg., processing, perm).
· Reviews each record for content of highly confidential/sensitive information and handles appropriately.
· Must be familiar with the following online policy manuals: Administration, Health Information Management Services, Safety.
· Demonstrates organizational competency by completing reconciliation and productivity as outlined.
· Maintains a positive working relationship and demonstrates teamwork within the department and other departments.
· Willing to accept additional assignments and/or provide temporary coverage for other areas as designated by Supervisor or Director.
· Reviews medical record documentation in each chart against a set of established standards and records variations/omissions in the chart deficiency module.
· Reviews all requests for PHI and ensures that proper authorization to disclose the information has been received, as needed. Returns defective requests for PHI.
· Process daily mail and logs in and out all requests for Protected Health Information (PHI) using the CORTRAK Correspondence Management System according to policy and procedure.
· Ability to locate and copy microfilm and/or microfiche records and coordinates retrieval of images from microfilm using the Papervision indexing system and readers/printers as needed.
· All appropriate outpatient and inpatient records are to be analyzed and completed within four (4) days or less of discharge.
· Enters deficiency data into computer for physician completion according to policy as needed.
· Follows CPOE procedures including changing deficiency status as needed.
· Demonstrates a thorough understanding of the Incomplete Records and ITS routines in Meditech.
· Assists physician incomplete clerk with coordination of physician notification and suspension policy and procedures as needed.
· Demonstrates thorough understanding of the Meditech chart deficiency management application.