Medical Records Staff

Position Summary

The Medical Records Staff manage medical information records, which include both electronic data and paper files.  They organize and keep track of patients’ medical histories and test results, both for facility, doctor, insurance and legal use.  Medical records staff use ethical principles and decision-making skills, and the knowledge of local, state, federal and other regulatory requirements necessary for the long-term care industry.

Position Responsibilities

The Medical Records staff has in-depth knowledge of medical technology, processes, and administrative duties.  This position must demonstrate excellent communication and organizational skills.  Responsibilities of the Medical Records Staff include (but are not limited to): 

• Promotes and maintains a focus of patient-centered care
• Adheres to laws, rules & regulations and practices ethical integrity and interpersonal skills
• Maintains compliance with long-term care regulations including federal, state and health regulations
• Responsible to the Director of Nursing  for ensuring accuracy, accessibility, and security of data
• Proficient in computer applications, data security and data analysis including the process and use of electronic health records (EHR)
• Gather patient demographic and personal information
• Issue medical files to persons and agencies according to laws and regulations
• Distribute medical charts to the appropriate departments of the facility
• Maintain quality and accurate records by following facility procedures
• Ensure patient charts, paperwork/electronic documentation and reports are completed and/or submitted  in an accurate and timely manner
• Make sure all medical records are protected and kept confidential
• File/store all patients’ medical records and information
• Supply the nursing department with the appropriate documents and forms as applicable
• Complete clerical duties including answering phones, responding to emails, and processing patient admission and discharge records as applicable
• Promote and set the example for resident rights helping protect and enhance those rights
• Perform position duties in a manner as to assure resident safety and rights are priority
• Adheres to the facility corporate compliance program and promotes the program in a positive and effective manner
• Performs other position-related duties as assigned, depending on assignment/shift setting

Other Responsibilities

• Follows facility OSHA safety rules and procedures
• Follows facility policies and procedures and adheres to federal and state regulations for long-term care
• Respects cultural and religious practices of patients
• Upholds HIPAA regulations
• Maintains a punctual and dependable attendance record
• Position Requirements
• High school diploma or equivalent qualification
• Minimum of (2) years LTC experience, preferred
• Federal, State, and MHI required credentials current and on file
• Cognitive skills as related to the position

Working Conditions

Because the nursing home provides round-the clock care, working hours may include days, nights, weekends and holidays.  An Administrator works in a climate controlled and well-lighted environment with a smoke-free policy.  Works in an office and walks throughout the building daily.  Has a low risk of exposure to infectious diseases, but receives training in handwashing practices and has access to personal protective equipment if direct exposure is anticipated.  Is subject to interruptions, noise, and odors daily.