Location: Oakdale, CA
Utilizes a working understanding of the clinical processes to achieve standard of care and documentation for the purpose of auditing records for completeness. Performs record reviews concurrently during resident stays and at the request of the Director of Nursing and/or Administrator. Codes all records on admission and discharge. Provides direction for the OVCC Health Information Management Clerk.
Provides assistance to all Medical Staff physicians, maintains accurate documentation of physician activity. Works with the Physician Representative in the acute Health Information Management department regarding physician suspensions.
1. Monitors chart review and confidentiality. Screens authorizations for release of information and assures all requests are handled appropriately. Processes all record requests on schedule and on demand following proper consent procedures.
2. Pulls charts, or delegates to Health Information Management Representative, for all requesting parties such as UR, Business Office, Review Agencies, Responsible Parties, etc., for review.
3. Codes and reports statistical data; assigns accurate diagnosis and procedure codes and communicates with all physicians to clarify appropriate code assignments as needed. Assures that any statistical information returned from OSHPD has been edited for re-submission as necessary.
4. Reviews general medical record and open medical records as directed by the Director of Nursing; audits admission, discharge and transfer records for complete, accurate documentation. Obtains and analyzes all pertinent information available in order to make the most informed decision based on factual and objective data.
5. Generates and reports CQI studies to Director of Nursing, Administrator and Medical Director monthly and CQI Committee quarterly.
6. Maintains and/or supervises maintenance of filing systems. Ensures efficient and timely processing of all medical records. All assembled records are filed in terminal digit order.
7. Ensures all patient encounters are combined into unit record format; record folders are accurately labeled with name and years and other stamps as appropriate. Verifies patient’s name and medical record number for accuracy. Tracks all discharged records for location and completion status.
8. Ensures all loose filing or daily mail has been identified with patient’s name and medical record number and incorporated into record in a timely manner. Files all returned/signed dictations and orders that come through the daily mail are filed into the proper patient/resident file in a timely manner.
9. Compiles out-guides on all charts leaving the department which tracks all records that leave the department by date and person/department responsible to assure timely return. Maintains and audits the checkout box weekly for accuracy on charts checked out of the department.
10. Routes appropriate information to physicians and assures all telephone order forms and dictated reports are sent out for signature and returned in a timely manner.
11. Audits general files on an ongoing basis checking for omissions or misfiles; reviews audit schedule and expected outcomes with Director of Nursing.
12. Reviews and audits admission and discharge records for completion; reviews audit schedule and expected outcomes with Director of Nursing.
13. Reviews and audits monthly MAR’s and TAR’s for omissions; reviews audit schedule and expected outcomes with Director of Nursing.
14. Provides training for OVCC Health Information Management Clerk(s) to ensure working knowledge of Health Information Management department functions as applied to day-to-day processes at the Care Center.
15. Provides in-service education regarding documentation practices to license staff during nursing meetings at the direction of the Director of Nursing. Is a resource for all documentation and clinical record processes for OVCC.
16. Assists in creating, revising and implementation of nursing policies and procedures as assigned.
14. Monitors physician compliance by reviewing all charts for completed documentation and signatures; holds physicians deficient as appropriate for missed visits, overdue discharge summaries and overdue history/physicals. Communicates weekly with the Chart Analyst in the Health Information Management department office regarding physician non-compliance and/or intent to suspend.
15. Prepares letters for physician notification of non-compliance to submit to the Medical Director for signature. Informs all appropriate staff regarding physician(s) who have been suspended and cannot admit residents. Provides quarterly report to Department of Medicine Committee on all physicians who are non-compliant. Provides information monthly of physician non-compliance to the Medical Director and Administrator.
16. Contributes to an effective and comprehensive plan of care for residents based on nursing diagnosis, expected outcomes and medical treatment plan. When appropriate involves resident, Responsible party and care providers in evaluation of residents’ progress. Uses ongoing assessment data to revise diagnoses, outcomes and plan of care as needed.
17. Answers telephone and responds to questions and requests appropriately.
18. Performs other job duties as defined by the Health Information Management Manager.
19. Meets standards of professional and ethical conduct.
20. Complies with other designated departmental policies and procedures.
High school graduate or equivalent required
Two (2) years’ medical records experience
Knowledge of filing systems, chart assembly, chart analysis, medical terminology, coding systems and word-processing
Thorough knowledge of confidentiality rules, and knowledge of State and Federal laws governing release of medical information
Familiar with telephone etiquette and general office procedures
Ability to operate a computer for records management
Demonstrate organizational abilities
Able to file alphabetically and numerically
Able to read, write and speak English fluently
Lifts, positions, pushes up to 50 pounds
Considerable reaching, stooping, bending, kneeling, crouching
Manual dexterity and mobility
Ability to move quickly
Frequent reach, twist, push and pull
Ability to adjust vision sufficiently to perform duties
Regularly exposed to the risk of contagious and blood borne diseases
Exposure to unpleasant elements (accidents, injuries, illness)
Subject to irregular hours
Increased stress due to multiple calls and inquiries
Able to work in spite of frequent interruptions
High exposure to communicable diseases and blood borne pathogens, rare exposure to toxic substances such as radiation, nuclear isotopes, chemotherapeutic agent