Electronic Medical Records Coordinator

Blue Heron•Wesley Chapel, FL

36d

About The Position

The Electronic Medical Records Coordinator coordinates, maintains, and administers the facility’s clinical records program in accordance with accepted record-keeping practices and applicable state and federal regulations. The role also includes training and oversight related to the electronic medical record system. The coordinator monitors medical records for completeness, accuracy, timeliness, and internal consistency; protects records from loss or destruction and maintains confidentiality; trains new employees on electronic medical record data entry and procedures; and audits admission, in-house, and discharge records within established time frames. The coordinator also develops systems for notifying relevant disciplines about documentation that needs completion or correction, works with the team to keep records current, and assembles discharge records to support continuity of care. Blue Heron Senior Living requires employees to provide proof of at least one COVID-19 vaccination as a condition of employment. Employees who believe they cannot be vaccinated for medical or religious reasons are asked to discuss this with the Human Resource Director.

Requirements

Must possess an active nursing license as an LPN.
Thorough understanding of the principles of best medical record practices.
Ability to follow written and verbal instructions, function independently, and make independent decisions when circumstances warrant.
Personal integrity and ability to deal tactfully with residents, family members, visitors, government agencies, and personnel.
Ability to adhere to a professional code of ethics.
Ability to relate information concerning a resident’s condition to appropriate staff members.
Must provide proof of at least one COVID-19 vaccination as a condition of employment; medical or religious concerns may be discussed with the Human Resource Director.

Responsibilities

Coordinate, maintain, and administer the clinical records program in accordance with facility record-keeping practices and state and federal regulations.
Train and oversee use of the electronic medical records system.
Monitor records for completeness, accuracy, timeliness, and internal consistency while residents are in the facility.
Protect medical record information, maintain confidentiality, and guard records against loss or destruction.
Train new employees on electronic medical record data entry and procedures.
Audit records for new admissions, in-house residents, and discharged residents according to established time frames, using appropriate forms and follow-up methods.
Develop and implement a system for advising disciplines about documentation that must be completed or corrected.
Work with the team to keep medical records up to date.
Assemble discharge records according to facility format, obtaining transfer information from referring health care providers as needed to support continuity of care.