Medical Records (Per-Diem)

Children's Health of Northern CA•Campbell, CA

5d•$27 - $30

About The Position

Medical records personnel are primarily responsible for processing, storing, and retrieving health information for the patients.

Requirements

Experience with PointClickCare is a plus
Working knowledge of medical terminology, MDS process, understanding of Title-22, OBRA Regs and Sub-Acute regs.
Must be able to read, write, speak and understand the English language
Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Able to make independent decision when circumstances warrant such action
Possess the ability to deal tactfully with personnel, resident family and visitors to facility
Knowledgeable in regulations and guidelines that pertain to long term care
Must have patience, tact, a cheerful disposition and enthusiasm as well as willingness to handle difficult patients
Be able to relate appropriate information concerning a patient’s condition
Having a working knowledge of ICD-9 Codes
Successful performance of essential functions can best be achieved through consistent application of current knowledge, use of good judgment, common sense, ability to establish and carry out priorities, effective use of interpersonal skills and ongoing communication with residents, staff, families, interdisciplinary team members, and government officials, including state surveyors and ombudsmen. Mobility, occasional lifting 25 pounds, stooping, bending, standing/sitting, hearing, speaking, good vision/color vision.

Responsibilities

Transcribed physician’s patient report.
Prepare quarterly reports to include the number of patients admitted, discharged home, expired, and discharged out of the hospital and what hospital they went to
Prepare annual report
Assist the medical staff and medical director by providing the data from the health record when requested for patient care view
Prepare a quarterly report for the quality assurance meetings
Order and maintain all necessary forms for patient documentation
OSHPD report twice a year regarding all discharges/medical qualification
Do patient face sheet in computer for all new admissions and update old face sheets as needed
Update all PT pictures quarterly
Order office supplies
Audit MAR/TAR daily (leave notes for nurses and rt with uncompliant) Run MAR/TAR after each month to make sure all errors have been taken care of
Audit UDA (making sure all documents/ assessments get locked and signed)
Scan and upload all documents on PCC in miscellaneous tab
Update patient all patient labels (name, food, feeding bags, ect.)
Make PT wristbands
To attend all department heads and quarterly meetings
To log all discharged patients in the computer
Close discharged charts and audit form for completion
Do all the ICD-10 coding for all patients
Process of release of records
Box all closed charts of the previous year and log them on the storage form to be sent to the storage unit
To work with D.O.N. and the task force on updating or signing new forms
Sign in all new admissions.
Prepare packets for admission.
Make name tags, for identification and any allergies.
Thin patients’charts during the last week of the month.
Review charts for appropriateness regarding new admits.
Audit patients’ charts quarterly to update yearly history and physical exam, chart completeness and proper physician’s signatures.
Clean and file charts after patients are discharged.
Filling all hospital paperwork at the end of the month as appropriate.
Monitor admission and discharge log on a weekly basis.
Check all patients’ armbands and allergy bands for clarity on a weekly basis, type and replace as needed.
Establishes filing systems that maintain accurate, consistent, and accessibility.
Conducts analysis of clinical records.
Communicates any health information deficiency (e.g., Nurse’s report. C.N.A. daily report) in patients’ binders to nursing supervisor.
Assemble records in the proper sequence.
Monitors physician services.
Update census in PCC
Train charge nurses to when admitting or discharging PT’s
Train charge to assign PT to rooms using the Masimo system
Send daily email of census
Print flowsheets for RT
Follow up with school aids regarding documentation for it to be scanned in
Scan and file overflow bin
Audit MD progress notes inform DON if Dr. is not compliant
Responses to State and/or Attorneys with appropriate documented approval form from the patient/patients’ guardian regarding patient’s records. Make copies when requested.
Prepare packets for discharge and patient doctor’s appointment.
Check completion of weekly summaries.
Check fax for any lab documents or dc summaries then upload in PCC
Respond to all emails and uploaded any documents into PCC that have been emailed
Open mail regarding TARS and send to billing
Any information requested by Billing, have DON OR DR sign and send immediately
Verify nursing hours daily for the State.
Submit hours for State requirement at the EOM.