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Medical Records Clerk-Days (Full-time)
SHENANDOAH VALLEY WESTMINSTER-CANTERBURY
POSITION DESCRIPTION
TITLE: Medical Records Clerk DEPARTMENT: Health Services
RESPONSIBLE TO: Director of Health Services/Nursing
JOB SUMMARY:
Compiles, verifies, types and files all medical records for all residents in accordance with State Regulations and SVWC Medical Records policies and procedures. Performs chart audits for completeness.
REQUIRED EDUCATION, EXPERIENCE, SKILLS:
1. High School diploma or equivalent with additional secretarial training or equivalent experience.
2. First Aid Certification required.
3. Previous experience in medical records maintenance required
4. Database management and project management required.
5. Ability to read, write and understand medical terminology.
6. Computer efficiency required, as well as standard office equipment.
7. Ability to sort, file, and assemble charts, records, forms and reports.
8. Effective written and verbal communication skills.
JOB REQUIREMENTS:
1. Support the mission and purposes of SVWC.
2. Support the Board of Trustees and Administration.
3. Present a professional, caring image.
4. Employment and annual tuberculosis testing as required by Virginia State Licensure.
5. Must attend mandatory in-services required by the State Licensure and all other mandatory in-services required by regulatory agencies and/or by SVWC.
6. Follows and supports the policies and procedures established by SVWC.
ESSENTIAL DUTIES/RESPONSIBILITIES:
1. Consolidates charts to ensure resident’s overflow is kept organized so that it is easily retrievable.
2. Frequently requests records from external parties on residents and scan into online database
3. Operates computer to enter and retrieve data and type correspondence and reports.
4. Compiles, verifies, types, and files medical records.
5. Completes requests for medical records in a timely fashion.
6. Reviews medical records for completeness, and files records in filing system.
7. Makes the admission packets for Health Care and Assisted Living admissions.
8. Orders and distributes all supplies from various vendors
9. Files medical records that are forwarded to the Medical Records department after resident discharges, and miscellaneous papers forwarded to the Medical Records Department.
10. Locates, signs out, and delivers medical records as requested.
11. Mails monthly Care Plan and Service Plan letters. Also mails Care Plan and Service Plan letters on all new admissions.
12. Gets medication list from Clinic on IL residents and faxes them to the doctor’s office for Mental Health visits. Print out face sheets and order summaries from electronic medical records. Enters Mental Health notes into electronic medical records.
13. Prepares charts for admissions to Health Care and Assisted Living. This includes getting DNR’s and medical records from external parties and Medical Records to ensure all records are ready for retrieval.
14. Assembles discharged resident’s medical records in a specific and chronological order and checks for missed signatures to keep medical records in compliance.
15. Prepares and faxes the monthly podiatry list. Maintains an accurate and up to date roster of each resident’s podiatry visit and which physician they see.
16. Prepares the monthly Recertification List for the neighborhoods. Keeps an accurate and up to date Recertification Roster.
17. Attends and takes and transcribes minutes at the Bi-Monthly Health Services Staff Meetings.
18. Performs audit monthly for SV initiated transfers and gives to Health Care Unit Coordinator.
19. Confirms and verifies doctor’s appointments for healthcare and ensures bus has been scheduled.
20. Makes name plates and folders for new staff members.
21. Sends out Healthcare Satisfaction surveys to discharge residents.
UNIVERSAL PRECAUTION RISK CLASSIFICATION:
Category D: The person holding this position understands Universal Precautions Risk Classification categories apply to this position and the individual may be exposed to AIDS, HIV, and Hepatitis B viruses. Tasks that involve no exposure to Blood, Body Fluids, or Tissues. The normal work routine involves no exposure to blood, body fluids, or tissues (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids).
PHYSICAL REQUIREMENTS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
VISION
- Must be able to visually identify and discern printed words on either typewritten pages or computer screen.
- Must be able to identify and differentiate colors.
- Must have depth perception within normal ranges.
HEARING
- Must be able to respond to spoken words and other auditory sounds including the ringing of telephone or beepers and monitors.
- Must be able to respond and communicate orally by telephone.
LIFTING
- Heavy lifting required (over 50 pounds occasionally and 25 pounds repetitively from ground level to shoulder height.)
- Must be able to push and maneuver carts/stretchers/space saver loaded with weights of 200 pounds.
- Must be able to bend, reach and lift patients with assistance to transport them to stretchers/wheelchairs.
TOOLS AND EQUIPMENT
- Must be able to use, operate and interpret information from equipment in work area.
SPEECH
- Must be able to verbally communicate in the English language directly and over the telephone and be understood.
RANGE OF MOTION
- Must be able to kneel, stand, and/or walk for 1 hour of an 8-hour shift.
- Must have mobility of all parts of the body, walking, bending, lifting, reaching above head and use of hands.
- Must have manual dexterity, fine motor skills (typing, computer, etc.)
- Some tasks may require sitting for 40% of the workday.
WORKING CONDITIONS
- Must be able to work under stress.
- Must be able to deal with verbally and physically combative patients.
MENTAL CAPACITY
- Must have mental capacity to fulfill the requirements of the job including problem solving, logic, communication and numerical calculations.
- Must be able to read and understand written instructions in English.
- Accurate recall and memory.
- Must be able to use judgment in making decisions and choices.
- Ability to analyze numbers and make basic mathematical calculations.
NOTE: This job description is not intended to be all-inclusive. An employee will also perform other reasonably-related job responsibilities as assigned by management as required. Shenandoah Valley Westminster-Canterbury reserves the right to revise or change job duties as the need arises. Moreover, management reserves the right to change job descriptions, job duties or working schedules based on their duty to accommodate individuals with disabilities. This job description does not constitute a written contract of employment.
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