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 medical records department with organizing, retrieving, assembling, checking, indexing, filing, and safeguarding resident records, and assists with assessments, committee work, correspondence, reports, and administrative duties. The position requires protecting confidential information, following facility procedures, and coordinating with personnel across departments. The position works in office areas and throughout the facility, with intermittent movement and frequent interruptions. Work may extend beyond normal hours and include weekends, holidays, other shifts, and emergency call-backs. The job may involve exposure to infectious diseases and waste, hazardous chemicals, air contaminants, equipment-related hazards, and emotionally upset individuals. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Requirements

High school diploma or GED.
Type at least 45 words per minute.
Ability to use dictation equipment.
Knowledge of medical terminology.
Knowledge of computers and data retrieval, input, and output functions.
Ability to read, write, speak, and understand English, including reading technical procedures.
Ability to apply fractions, percentages, ratios, and proportions to practical situations.
Ability to make independent decisions when circumstances warrant, follow written and oral instructions, and deal tactfully and harmoniously with personnel, residents, visitors, and the general public.
Ability to minimize waste and misuse of supplies and equipment, and willingness to seek out 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.
Ability to move intermittently throughout the workday and cope with the mental and emotional stress of the position.
Adequate sight and hearing, with or without prosthetics, to perform the position’s requirements.
Ability to push, pull, move, or lift at least 25 pounds to a height of at least 5 feet and carry or move that weight at least 50 feet.
Must meet the facility’s general health requirements, including a medical and physical examination.
May need to assist in evacuating residents during emergencies.

Nice To Haves

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

Responsibilities

Follow the work schedule, supervisor instructions, and established facility policies and procedures.
Assist in organizing, planning, and directing the medical records department, and assist the Medical Records/Health Information Consultant as required.
Maintain meeting minutes and file them as necessary.
Maintain effective working relationships with personnel in other departments to support proper maintenance of medical records.
Assist in recording incidents and accidents and file documentation according to established procedures.
Retrieve resident records manually or electronically and deliver them as needed.
File nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, and other information in resident charts.
Collect, assemble, check, inspect, and file resident charts, ensuring they are in proper order and complete.
Assist the MDS Coordinator with scheduling assessments in accordance with facility and OBRA guidelines.
Ensure incomplete records are returned to the appropriate departments or personnel for correction.
Assist in developing procedures for completing, assembling, coding, signing, indexing, and filing resident records.
Help ensure resident charts do not leave the medical records room except as authorized by facility policy.
Maintain records of information released from charts, including the information type, recipient, date, and department.
Abstract records information for insurance companies, Medicare, Medicaid, VA, and other authorized purposes in accordance with current 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.
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.
Retrieve medical records for authorized personnel, including physicians, nurses, and government agencies or personnel.
Ensure records removed from the department are signed out and signed in upon return.
File active and inactive records in accordance with established policies.
Protect assigned user ID codes, passwords, and residents’ protected health information; promptly report suspected or known disclosure violations to the Administrator.
Report known or suspected unauthorized attempts to access the facility 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 for staff or other committees as directed.
Report known or suspected fraud to the Administrator, including suspected fraud related to false billings, cost reports, or kickbacks.
Ensure unattended departmental workstations are logged off or protected by the facility-approved automatic screen-saver settings.
Attend and participate in mandatory facility in-service training and approved workshops or seminars.
Immediately report unsafe or hazardous conditions and defective equipment to a supervisor.
Report equipment malfunctions or breakdowns promptly, replenish supplies as needed, and keep work areas clean with records and files properly stored.
Perform other duties as assigned.