medical records director

POSITION SUMMARY: 
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 county, state and federal laws and regulations, as applicable, for long term care facilities.  Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible and systematically organized.    
REPORTING: 
This position is responsible to the Administrator   
FLSA STATUS:      Non-Exempt 
 

ESSENTIAL JOB FUNCTIONS: 

• Perform health record maintenance duties; assembling, labeling, cleaning, filing and purging documents 
• Keys information into computer systems, including EMR 
• Maintain stock of forms and record supplies 
• Request necessary resident information from transferring facilities 
• Process external information requests from authorized institutions and individuals 
• Compile statistical data at the direction of Administrator 
• Prepare Alirts (OSHPD) yearly report 
• Maintain the confidentiality and physical security of health records in accordance with HIPPA rules and regulationS 
• Perform concurrent and discharge quantitative audits of health records.  Physician visit audits.  Notification of physician when required by procedure 
• Develop and perform specialized audits on a predetermined time sequenced rotation with plan of completion to be defined and time limited.  Audit all current resident charts to notate deficiencies and obtain and assist in corrections on a scheduled basis.  Submit deficiency reports and to persons responsible for correction with date of completion to be returned (3 days) to the Administrator, Director of Nurses or designated representatives.  These audits will include but are not limited to: 
  • Admission audits within 24 or 48 hours, 
  • 7th   14th  &  21st day    
  • Discharge Charts
  • Skin and pressure sores     
  • Weights - Weekly/Monthly 
  • Foley Catheter, Intake and Output  
  • ADL records 
  • Diabetic     
  • Lab/X-Ray 
  • Special Therapy, i.e., IV, PT, OT, Inhalation, Tube Feeders, etc.   
  • Medicare Q shift Charting 
  • Psychotropic   
  • Current H & P 
  • Nursing Weekly Progress Notes     
  • Physician Visits 
  • Bowel and Bladder   
  • Plan of Care - entries of each discipline 
  • Medications and Treatments     
  • Change in condition - Daily 
  • Telephone Orders   
  • Quarterly Progress notes - Activity, Dietary, Social Service, Discharge Planning. 
  • MDS - Initial, Quarterly, Yearly, Change in condition   
  • Accidents/Incident Reports 
  • Intensity of Care Directives
• Disease index coding at time of admission, when diagnostic status alters and within 30 days of discharge date.  Complete any outstanding disease index coding 
• Discharge charts must include the following information prior to filing: 
  • Final Diagnosis and/or Death Certificate 
  • Completed Disease Index Coding 
  • Obtain all outstanding documentation and required signatures to meet criteria mandated by facility policy. 
• Mail telephone order forms to physicians daily, assure prompt return and file in chart 
• Prepare Physician Orders, Medication/Treatment records, ADL records and Resident Care Plans for accurate input into computer and printing on scheduled basis 
• Perform computer operation functions including regular input of data and printing on a scheduled basis 
• Keep computer terminal(s), keyboard(s) and office clean and functional 
• Maintain appropriate medical record storage and destruction of medical records consistent with facility policy 
• Follow-up on reports and recommendations submitted by the Medical Records Consultants and Service Center Medical Records Analysts 
• Report to the Director of Nursing and Administrator significant documentation problems 
• Attend and participate in in-service education and staff meetings as required, including risk management and daily stand-up meetings.  Maintain minutes of meetings/files as requested 
• Be courteous, considerate and cooperative when communication with all facility personnel, resident and public 
• React appropriately to emergencies and disaster situations 

JOB FUNCTIONS: 

• Demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions 
• Appreciates the importance of maintaining confidentiality of resident and facility information 
• Demonstrate honesty and integrity at all times in the care and use of resident and facility property 
• Must be able to key information into computer systems 
• Able to understand and to follow written and/or verbal directions.  Able to express self adequately in oral and/or written communication.  Able to communicate effectively with staff members, other professional staff, consultants and residents 
• Demonstrates ability to prioritize tasks/responsibilities and complete duties/projects within allotted time 
• Able to respond to change productively and to handle additional tasks/projects as assigned 
• Able to carryout the essential functions of this job (with or without reasonable accommodation) without posing specific, current risk of substantial harm to health and safety of self and others 
• Other duties as assigned by the Administrator 

PHYSICAL CAPACITIES:   (With or Without the Aid of Mechanical Devices) 

• Must be able to move intermittently throughout the workday. 
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met. 
• Must meet the general health requirements set forth by the policies of this facility which includes an annual TB screening and physical examination.  
• Must be able to sit for extended periods of time. 
• Must be able to lift and carry up to 25 pounds.   
• Must be able to cope with the mental and emotional stress of the position. 

 
ENVIRONMENTAL CONDITIONS:      
Primarily inside work, normal temperatures, some noise, occasional fumes/odors, chemical exposure and potential exposure to bloodborne pathogens. 
This job cannot be performed without exposure to the stresses associated with an intimate, 24 hour skilled care environment that delivers care and services primarily to disabled and cognitively impaired residents in an aging population.  Examples of these stresses include, but are not limited to: emergency health or safety response, weekend and holiday duty, unusual or impaired behavior by residents, family reactions to having a loved one in a nursing home, death and dying, oversight of state surveyors, ombudsmen and federal officials, presence of consultants and attorneys, and variable involvement of medical staff. 
 

QUALIFICATIONS/REQUIREMENTS: 
Education:       
    High School graduate or equivalent  
License:       
    None Required 

Work Experience:     

• At least on year of clerical experience, including filing 
• Experience as a medical records practitioner in long term care facility preferred Ability to type, calculate and perform data entry skills 

Language Skills: 

• Must be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language.   

Mathematical Skills: 

• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. 
• Ability to perform these operations using units of weight measurement, and volume. 

Communication Skills: 

• Must have exceptional communication and customer service skills, and be empathetic.   
• Ability to effectively communicate with patients, families, responsible parties, staff and outside resources and agencies.