Medical Records Clerk requires a high degree of organizational skills and a great deal of attention to deal. The ability to work successfully in a high traffic area with frequent interruptions is necessary. This position requires a professional appearance and a willingness to accept supervision. There is a commitment to strict confidentiality in respect to resident's status and Medical Records, as well as the ability to work well with co-workers, demonstrating integrity and a sense of humor.
The primary responsibility is to serve as a liaison with key unit personnel who handle admission, transfers and discharges, laboratory work, appointments, Medical Record and resident charting.
- Prepares resident charts on admission, labeling pages and making sure necessary documentation is completed.
- Assembles and maintains all Medical Records.
- Assembles and maintains standard forms for resident's charts, records, graphs, BP, TPR and other routine information on flow sheets and care plans.
- Assists in scheduling of resident care conferences and communicates this information to all concerned.
- Arranges for all appointments and referrals, and any transportation required.
Monitor physician orders to ascertain that all orders are signed in a timely manner.
- Transcribe all physician orders. Request Nurse to review transcription for accuracy and signatures.
- Answer and screen telephone calls at the nurse's stations.
- Assist with the admission, discharge, and transfer process by preparing the necessary paperwork.
- Assist with checking charts, medication sheets and treatment sheets.
- Attend regular in service and staff meetings.
- Complete lab requisitions and arrange for lab work to be drawn.
- Order oxygen cylinders, stationary supplies and medical supplies as needed.
- Obtain photos for resident's charts for identification purposes within 72 hours of admission.
- Prepare necessary forms for each new month, within the first five days of the month.
- Complete inventory forms and restock nurses stations / conference rooms on a weekly basis.
- Ensure resident ID bands re legible by checking bands on a regular basis.
- Assist in planning and support changes and improvements.
- Take initiative for following up on concerns or problems that are identified.
- Maintains up to date list for audits.
- Responsible for time sheets and payroll updates.
- Manage petty cash and other accounting duties as needed.
- Participate in data input with RAI / MDA