Medical Records Assistant

PACS

About The Position

The Medical Records Assistant maintains resident medical records and health information systems in accordance with current federal and state guidelines and the facility’s privacy policies and procedures. The role supports the organization and operation of the medical records department, maintaining and retrieving records, processing authorized information requests, and helping ensure records are complete, properly handled, and securely stored. The position also provides administrative and secretarial support to facility committees, assists with assembling records and preparing reports, attends required training, and reports safety, equipment, or information-security concerns. The employee works in office areas and throughout the facility, interacts with residents, families, staff, and external personnel, and may work beyond normal hours, weekends, holidays, or other shifts as needed, including call-back during emergencies. The role requires a high school diploma or GED, typing at least 45 words per minute, the ability to use dictation equipment, knowledge of medical terminology, and computer skills for data entry and retrieval. On-the-job training in medical records and health information procedures is provided. Preferred but not required knowledge includes medical terminology, anatomy and physiology, legal aspects of health information, coding, and indexing.

Requirements

High school diploma or GED at minimum.
Ability to type at least 45 words per minute.
Ability to use dictation equipment.
Knowledge of medical terminology.
Computer knowledge, including data retrieval and input/output functions.
Ability to read, write, speak, and understand English and read technical procedures.
Ability to apply fractions, percentages, ratios, and proportions to practical situations.
Ability to make independent decisions when circumstances warrant.
Ability to deal tactfully with personnel, residents, visitors, and the general public, and to work harmoniously with other personnel.
Ability to minimize waste and misuse of equipment, follow written and oral instructions, and incorporate new methods and principles into existing practices.
Must not pose a direct threat to the health or safety of others in the workplace.
Must be able to move intermittently throughout the workday, cope with mental and emotional stress, and communicate in understandable English.
Must have adequate sight and hearing, with prosthetics if needed, to perform the position’s requirements.
Must function independently and demonstrate personal integrity, flexibility, and ability to work effectively with other personnel.
Must meet the facility’s general health requirements, including medical and physical examination.
Must be able to push, pull, move, and/or lift at least 25 pounds to a minimum height of 5 feet and move or carry that weight at least 50 feet.
Must be able to assist with resident evacuation during emergencies if necessary.
Work may involve frequent interruptions, work beyond normal hours, weekends, holidays, other shifts, or emergency call-back.
May encounter fall and equipment-related hazards, odors, dust, disinfectants, tobacco smoke and other air contaminants, infectious waste and diseases including TB, AIDS, and Hepatitis B, hostile or emotionally upset individuals, and hazardous chemicals.

Nice To Haves

Working knowledge of anatomy and physiology.
Working knowledge of legal aspects of health information.
Working knowledge of coding and indexing.

Responsibilities

Follow the supervisor’s work schedule and instructions and established facility policies and procedures.
Assist in organizing, planning, and directing the medical records department and support the Medical Records/Health Information Consultant as required.
Maintain meeting minutes and file them as necessary.
Maintain productive working relationships with facility personnel and departments so medical records can be properly maintained.
Assist in recording and filing incidents and accidents.
Retrieve resident records manually or electronically and deliver them as needed or when requested by authorized personnel.
File clinical and administrative information in resident charts, including nurses’ notes, assessments, progress notes, laboratory reports, x-ray results, and correspondence.
Collect, assemble, check, inspect, and file resident charts, ensuring they are complete and in proper order.
Assist the MDS Coordinator with scheduling assessments under facility and OBRA guidelines.
Return incomplete records or charts to the appropriate departments or personnel for correction.
Assist in developing procedures to ensure records are completed, assembled, coded, signed, and indexed before filing.
Ensure resident charts and records leave the medical records room only as authorized by facility policy.
Maintain records of information released from charts, including information type, recipient, date, and department.
Abstract information from records for insurance companies, Medicare, Medicaid, VA, and other authorized purposes in accordance with privacy rules.
Index medical records as directed by the medical records/health information consultant.
Maintain assigned registries, including resident admission and discharge registers.
Transcribe and type physician reports as necessary.
Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas as necessary.
Batch resident information into the computer and retrieve demographic information as appropriate or instructed.
Answer telephone inquiries about medical records functions and prepare written correspondence as necessary.
Ensure records taken from the department are signed out and signed in upon return; file active and inactive records according to established policies.
Protect assigned user ID codes, passwords, and resident protected health information, and promptly report suspected or known disclosure violations to the Administrator.
Report known or suspected unauthorized attempts to access the facility’s information system.
Perform assigned duties with the administrative authority, responsibility, and accountability delegated for the position.
Perform secretarial duties for facility committees as directed; collect and compile records for committee review and prepare reports as requested.
Report known or suspected fraud to the Administrator, including fraud related to false billings, cost reports, or kickbacks.
Ensure unattended departmental computer workstations are logged off or protected by the automatic screen-saver in accordance with facility policy.
Attend and participate in mandatory in-service training and approved workshops or seminars.
Report unsafe or hazardous conditions and defective equipment to the supervisor promptly.
Report equipment malfunctions or breakdowns and ensure supplies are replenished as necessary.
Keep work areas clean and ensure records and files are properly stored before breaks or the end of the workday.
Perform other duties as assigned.
Move intermittently during the workday and meet the role’s stated physical demands, including moving or carrying at least 25 pounds as specified.
Assist in evacuating residents during emergency situations if necessary.