Medical Records

Baptist Convalescent Center, Inc.Erlanger, KY, US

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Job Description

MEDICAL RECORDS

JOB DESCRIPTION

MISSION STATEMENT

In using the ministry of Jesus Christ as our model, we seek to provide quality of life options to assist adults 55+ to remain active by maintaining a healthy lifestyle.

VISION STATEMENT

People Matter. Life is Precious. Make Someone’s Life Better.

RESPONSIBLE TO

Director of Nursing.

EDUCATION, QUALIFICATIONS AND CREDENTIALS

Must possess a basic knowledge of health care terminology, basic knowledge of the legal aspects of health information privacy and confidentiality. Must possess basic knowledge of the ICD-10 statistical classification system. Must possess and display organizational and communication skills and demonstrate the ability to work effectively with all levels of personnel.

JOB ROLE

Recognize your role as part of the QAPI efforts of your organization.
Attend trainings to build understanding and capacity to undertake QAPI work.
Carry out QAPI roles and responsibilities as assigned.
Follow established policies and procedures in support of QAPI efforts.
Look for, and share with leadership, ideas for improvement in the organization.
Communicate to leadership upon witnessing a positive outcome of a QAPI project or detecting barriers preventing project success.
Support QAPI efforts both verbally and non-verbally (i.e., via actions and attitude), including adjusting performance and practice in accordance with QAPI initiatives and findings.

ESSENTIAL JOB FUNCTIONS

Consistently model and demonstrate excellence in customer service, with a constant focus on person-centered care / services delivery.

Maintain complete and well organized closed (discharged) medical records ensuring proper chronology. Also maintain active medical records if he / she is uploading information in PCC.

Conduct periodic, random audits of active (in-house) medical records for both quantitative and qualitative data.

Notify appropriate individual(s) when a medical record is incomplete as needed.

Maintain a sign-out log for medical records(s) removed from the department and follow up as necessary.

Maintain the legal confidentiality and physical security of medical records as required by HIPAA and / or other regulations.

Determine proper release of medical record information in response to proper informational requests in compliance with HIPAA and / or other regulatory guidelines.

Code diagnoses and services provided with ICD-10 statistical classification as deemed necessary.

File medical record information in a timely manner and thin / purge medical records in accordance with facility policy.

Report any allegation of abuse, neglect, exploitation or misappropriation of resident property per facility policy.

Participate in the Quality Assurance Program as requested or directed.

Maintain stock of forms and record supplies.

KNOWLEDGE, ABILITIES AND SKILLS

Knowledge of current federal and state laws and regulations that apply to the practice of nursing in a long-term care setting. Has strong organizational and time management skills and the ability to prioritize responsibilities. Ability to define problems, collect date, establish facts and draw valid conclusions.

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Medical • Erlanger, KY, US