Job Description

OBJECTIVE

The Medical Records position is responsible for maintaining, incorporating, and accurately accounting for all medical records information on each individual resident.

PRIMARY DUTIES AND RESPONSIBILITIES

The employee must be able to perform the essential functions of the job with or without reasonable accommodations. Except as specifically noted, the following functions are considered essential to this position.

Responsible for accessing, maintaining and auditing all medical charts. Closes and files discharged residents' medical charts. Reviews charts of discharged residents for the deficient information and ensures compliance for correction of deficient documentation. Scan documents and file them in a resident's medical chart in a systematic order. Ensure that each section of the resident's record is maintained in a neat, organized and readable format. May require analysis of appropriate medical records to be attached to a particular quality assessment electronic tools. Provide Documents and guidance for all assessments. Creates schedules for assessments within the medical record. Prepares assessments for completion and appropriately correlates assessments to the electronic schedule. Ensures that Physician's orders, telephone orders and other records requiring signatures are received and filed within the required time frame. Maintains effective communication with others, both inside and outside the department, to give or obtain needed information or coordinate activities of residents (e.g., doctors' appointments). Ensures that all residents are seen by their physicians, and routine lab work is completed and filed in the required time frames. Ensures personal and staff compliance with all State and Federal regulations including blood-borne pathogens, infection control, use of hazardous materials, and fire safety. Ensure personal and staff compliance to Residents' Rights. In-Service training, and assigned QA meetings. May be assigned to chair or make presentations at these events. May be called upon to respond to an admission inquiry; to host a prospective resident or family member; or to visit a prospective resident at home or in the hospital. Is responsible for knowing the relevant State and Federal regulations and laws; especially as related to the provision of resident care and documentation. Physical Activity Requirements: Employee is required to use transfer/gait belts or to obtain the assistance of another employee when attempting to assist residents or when lifting or carrying objects in excess of 25 lbs. Employee must be aware that during the normal, routine performance of the essential functions, some of the following body movements may occur naturally, although they may not be a requirement of the job. Employee may be requested to perform other duties or tasks that are not listed, but are within the competence and training of the individual.

PHYSICAL DEMANDS AND REQUIREMENTS:

Lift up to 10 lbs: Constantly


Lift 11 to 25 lbs: Occasionally


Lift 26 to 50 lbs: Rarely


Lift over 50 lbs: Rarely




Carry up to 10 lbs: Constantly


Carry 11 to 25 lbs: Occasionally


Carry 26 to 50 lbs: Rarely


Carry over 50 lbs: Rarely




Reach above shoulder height: Frequently


Reach at shoulder height: Frequently


Reach below shoulder height: Constantly




Push/Pull: Frequently


Grasping: Frequently


Handling: Constantly


Torquing: Not required


Fingering: Constantly




Twisting: Not Required


Bending: Required


Crawling: Not Required


Squatting: Not Required


Kneeling: Not Required


Crouching: Not Required


Climbing: Not Required


Balancing: Not Required




During an 8 hour day, Employee is required to:




Consecutive Hours Total Hours




Sit 2 6


Stand 1 1


Walk 1 1




Work Surface: Varies from tile, hardwood, linoleum and carpet




Cognitive and Sensory Requirements:




Talking: Not Required


Hearing: Not Required


Sight: Required


Tasting and Smelling: Not Required

WORK ENVIRONMENT

This job operates in a clerical, office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. This is an extremely sedentary position where the employee is required to sit for prolonged periods. Employee is able to sit and stand as tolerated.


Summary of Occupational Exposures:




Bloodborne Pathogens:


Tasks and procedures performed by employee involve risks classified by CDC as: Category III (Task/activity does not entail predictable or unpredictable exposure to blood.)




Specific Task Exposure:




General Resident Care: Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions, other body fluids - cerebrospinal, synovial, pleural, peritoneal, pericardial, amniotic;



Handling Soiled Linens and Clothing: Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions, other body fluids - cerebrospinal, synovial, pleural, peritoneal, pericardial, amniotic.



Cleaning Resident Rooms and Common Areas - Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions.



Refer to Exposure Control Plan for additional information.

#BCS123