Medical Records Assistant

PACS

22h

About The Position

The Medical Records Assistant maintains resident medical records and health information systems in accordance with current federal and state guidelines and facility privacy policies and procedures. The role supports the organization and day-to-day operation of the medical records department, including organizing, retrieving, assembling, reviewing, indexing, filing, and protecting resident records. The assistant also supports facility committees, personnel, and the MDS Coordinator; handles authorized information requests and record releases; and participates in staff training and safety practices. The position requires a high school diploma or GED, typing at least 45 words per minute, use of dictation equipment, computer skills, and knowledge of medical terminology. On-the-job training in medical records and health information system procedures is provided. A working knowledge of anatomy and physiology, legal aspects of health information, coding, and indexing is preferred but not required. The role works in office areas and throughout the facility, involves frequent interruptions and possible work beyond normal hours, on weekends, holidays, or other shifts, and may require responding to emergencies.

Requirements

High school diploma or GED.
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 and 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 work harmoniously with other personnel.
Ability to follow written and oral instructions, seek out new methods and principles, and incorporate them into existing practices.
Ability to minimize waste of supplies and misuse of equipment.
Must not pose a direct threat to the health or safety of others in the workplace.
Ability to move intermittently during the workday and cope with the mental and emotional stress of the position.
Adequate sight and hearing, with prosthetics if needed, to perform the job requirements.
Ability to push, pull, move, and/or lift at least 25 pounds to a height of 5 feet and carry or move that weight at least 50 feet.
May be required to assist with resident evacuation during emergencies.
Must meet facility general health requirements, including a medical and physical examination.

Nice To Haves

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

Responsibilities

Follow the supervisor’s work schedule and instructions and established 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.
Develop and maintain effective working relationships with facility departments and personnel to support proper maintenance of medical records.
Assist in recording incidents and accidents and file the records according to established procedures.
Retrieve resident records manually or electronically and deliver them as necessary.
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 in proper order, ensuring completion.
Assist the MDS Coordinator with scheduling assessments according to facility and OBRA guidelines.
Return incomplete records or charts to the appropriate department 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 do not leave the medical records room except as authorized by policy.
Maintain records of authorized information released from charts, including information type, recipient, date, and department.
Abstract record information as authorized or required for insurance companies, Medicare, Medicaid, the VA, and other purposes in accordance with privacy rules.
Index medical records as directed by the medical records or health information consultant.
Maintain assigned registries, including resident admission and discharge registers.
Transcribe and type reports for physicians as necessary.
Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas.
Enter 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 records requested by authorized personnel, including physicians, nurses, and government agencies or personnel.
Ensure records removed from the department are signed out and signed in when returned.
File active and inactive records according to established policies.
Protect assigned user ID codes, passwords, and resident 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 as requested.
Report known or suspected fraud to the Administrator, including fraud related to false billings, cost reports, or kickbacks.
Ensure unattended departmental workstations are logged off or protected by the facility’s automatic screen-saver 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, replenish supplies as needed, and keep work areas clean with records and files properly stored.
Perform other duties as assigned.