Medical Records Director

PruittHealth•Aiken, SC

1d•Onsite

About The Position

The Medical Records Director assumes authority, responsibility, and accountability for the record-keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long-term care facilities. This role establishes and implements policies to ensure that records are complete, accurately documented, readily accessible, and systematically organized. The Director collaborates with the Nursing Home Administrator to allocate department resources efficiently and economically to achieve department objectives.

Requirements

High school diploma or equivalent.
One (1) year experience as a medical records practitioner in a long-term care facility.

Nice To Haves

Current certification as an Accredited Records Technician.
Certification as a Registered Records Administrator.

Responsibilities

Ensures that all clinical records contain sufficient information to identify the resident, a record of the resident’s assessments, the plan of care and services provided, the results of any preadmission conducted by the State, and progress notes.
Initiates and participates in the development of facility policies and procedures to ensure that medical records are complete, accurately documented, readily accessible, and systematically organized.
Develops and implements a record storage and retrieval system that complies with applicable record retention laws and maintains accessibility of records.
Inspects closed records for completeness and systematically organizes closed medical records for long-term storage. Reports delays in completing records to the Nursing Home Administrator.
Develops and maintains appropriate safeguards against unauthorized access and use of computer-based medical records.
Evaluates medical records forms and record format, making recommendations for change to continuously improve the quality of facility records and record-keeping practices.
Evaluates, through record reviews of open and closed records, compliance with medical record documentation policies and reports findings to the Nursing Home Administrator and Director of Nursing Services.
Develops and conducts educational programs for facility staff to explain and discuss documentation policies and practices. Provides training and staff development opportunities to ensure staff can distinguish between confidential/non-confidential information and release information only in compliance with facility policies.
Maintains, updates, and distributes the lists of facility-approved abbreviations and definitions.
Provides access to all records pertaining to residents (including the current medical record) within 24 hours of an oral or written request from a resident or legal representative. Makes photocopies available within two working days of the request.
Develops and implements safeguards against loss, destruction, unauthorized access, or use of clinical record information, including procedures to maintain the confidentiality of all information contained in a resident’s record and to obtain authorized consents to release information. Releases information without written consent of the resident or legal representative only when required by law.
Advises Administration, physicians, and facility staff on applicable requirements regarding the control, use, and release of clinical information. Advises Administration on ways to safeguard the confidentiality of medical records of facility staff.
Conducts periodic quality control assessments of staff implementation of medical records policies and procedures. Analyzes findings and develops/implements ways to improve performance.
Collects and displays clinical data requested by Administration, facility committees, regulatory agencies, or accrediting bodies.
Participates in the development of the department budget and provides relevant financial information to the Nursing Home Administrator regarding department financial needs and status.
Communicates with the Nursing Home Administrator on a daily basis to discuss medical record and budget issues. Recommends to the Nursing Home Administrator the numbers and types of personnel needed to meet facility needs in compliance with state and federal laws and regulations.
Actively participates in the long-term care survey process by instructing staff in matters of conduct and disclosure, maintaining a presence at all times surveyors are on-site, and directing the timely collection of information required by the survey team.
Demonstrates concern for identified problems and undertakes corrective action while the survey is in progress if appropriate. Gathers and presents supplemental documentation to avoid potential deficiencies. Collaborates with the Nursing Home Administrator to develop responses to survey reports as needed.
Maintains current skills and knowledge through continuing education and applies information to job responsibilities.
Performs other duties as assigned by Supervisor.