Medical Records

Part-time Medical Records
Reports To: Director of Nursing

Supervisors: Position requires no supervision of other staff members.

Medical Records Requirements:

• Must have at a minimum a high school diploma or the equivalent.

• Must have at a minimum a limited ability to use computers, electronic systems, and basic EMR/EHR platforms.

• Must have understanding of chart management, medical documentation, and filing organizational systems within a healthcare or long-term care setting.

Medical Records Duties:

• Maintain nursing/medical records mail log in accordance with facility policy and HIPAA guidelines.

• Maintain record of admissions and discharges for skilled nursing and long-term care residents.

• Prepare new charts for incoming residents, ensuring accurate documentation setup.

• Place ICD-10 codes and diagnoses on facesheet and cumulative diagnoses sheet for proper clinical documentation and compliance.

• Close out charts for discharged residents in accordance with regulatory compliance standards.

• Maintain an organized filing system for resident medical records and health information management.

• Ensure that physicians have signed all necessary forms in chart including P.O. forms – this will require both mailing of the documents and communication with physicians periodically.

• Ensure that physicians perform annual physicals for each resident per regulatory guidelines.

• Audit each chart within 2 weeks of a new admission for necessary initial assessments (social services, dietary, activities, nursing) to ensure interdisciplinary documentation compliance.

• Audit each chart periodically for necessary documents including nurse’s notes, monthly summaries, weights and vital signs, physician progress notes, and physicals.

• Thin charts every three months and/or at discharge in accordance with medical records retention policies.

• File medical records in resident charts including:

  • Telephone Orders

  • MDS Records/Care Plans

• Maintain stock of nursing forms at nurse’s station for use by clinical staff.

• Assist in keeping nurses station clean and organized to support clinical workflow.

• Assist in responding to phone calls and family/resident concerns in a professional healthcare environment.

• Maintain nurses station fax machine including the replacement of ink cartridges and adding paper.

• Participate in quality assurance and performance improvement functions including but not limited to:

  • Acting as secretary to the Quality Assurance Committee including keeping minutes, scheduling meetings, and sending meeting notices.

• All other duties as assigned by supervisor.