DALLAS RETIREMENT VILLAGE

Medical Records Assistant

Position Title: Medical Records Assistant

Department: Health Care Services

Exempt Status: Non-Exempt

Position Type: Part-time, Monday through Friday 12:00pm to 6:00p,

Supervisor: Director of Medical Records

GENERAL SUMMARY:

To assist the Director of Medical Records in maintaining Medical Records in accordance with federal, state, local and facility standards, guidelines and regulations, and as may be directed by the Director of Nursing.

PRINCIPAL DUTIES:

Essential Job Duties:

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  Maintains the confidentiality of all information they come in contact with through the performance of their duties. This includes the written and spoken word.

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  Attends and participates in departmental meetings.

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  Maintains knowledge of and complies with facility departmental policies and procedures.

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  Performs various clinical records duties in the absence of others within the department.

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  Assists in prompt retrieval of clinical records for authorized personnel.

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  Answers telephone, handles incoming and outgoing communications concisely and accurately and relays information to the appropriate persons.

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  Verified the admission, discharge, and transfer information, copies and distributes the 24 hour report, distributes inter-facility mail, distributes Incident Reports for department signature.

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  Maintains department registers including the Medical Records log, the admit and discharge register, and the master resident index.

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  Maintains, completes and mail monthly Death Report to State Vital Records Department.

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  Updates Census Roster daily using information from 24 hour report.

11. Enters all resident’s socio-economic data into resident demographics on computer system for new admits and on-going. Maintains the accuracy of the information in resident’s demographics in the computer and make appropriate changes on resident’s active record.

• Prepares all charts for admission.

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  Prepares and prints AOL flow sheets and face sheets for new admissions.

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  Transcribes orders into computer system at the time of admission as directed by the nursing department. Performs other clerical duties relating to the admission procedures.

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  Inputs appropriate Telephone Orders in the computer system as needed.

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  Files loose chart material and required forms resident charts and prescribed, and files other department documents as required.

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  Assists nursing staff with document preparation in emergency transfer of residents.

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  Copies lab reports, distributes copies and files originals on resident’s active record after review by RCM.

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  Fills out Parameter Flow Sheets, Behavioral Monitoring and Psychoactive Drug sheets for appropriate residents monthly.

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  Assists in performing audits of medical records as needed.

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  Processes Monthly Physician Orders.

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  Prints monthly reports, Medication, PRN, Treatment, Restorative, Physician Orders, and AOL Sheets.

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  Disassembles charts of discharged residents in discharge chart order and stores in Medical Records.

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  Prepares and mails monthly reports to all appropriate Physicians indicating needed Physician Visits and Annual Assessments for the upcoming month to cover all residents.

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  Performs all duties in a safe manner

Other Duties:

1. Basic Skills

a. Dependability, punctuality, creativity, initiative, enthusiasm, flexibility, and patience.

b. Ability to communicate effectively, verbally and in writing (in English).

c. Have basic computer skills; Microsoft Word, Outlook, Gmail or like e-mail ability.

2. Interpersonal Skills

d. Sensitivity to the needs, interests, and abilities of residents.

e. Ability to organize, and direct others; assume and delegate responsibility; accept advice and consultation.

3. Mental Skills

f. Moderately complex problem solving.

g. Excellent safety judgment.

4. Sensory Skills

h. Constant use of sight, hearing and speech for reading, identification, safety and communications.

i. Intermittent use of touch.

HOSPITALITY FOCUS:

Dallas Retirement Village fully embraces a culture of hospitality. To that end, we include the following hospitality promises as a guide for our interpersonal interactions with residents, co-workers, and guests:

• We greet residents, employees and guests warmly, by name and with a smile.
• We treat everyone with courteous respect.
• We strive to anticipate resident, employee and guest needs and act accordingly.
• We listen and respond enthusiastically in a timely manner.
• We hold ourselves and one another accountable.
• We embrace and value our differences.
• We make residents, employees and guests feel important.
• We ask “Is there anything else I can do for you?”
• We maintain high levels of professionalism, both in conduct and appearance, at all times.
• We pay attention to details.

WELLNESS FOCUS:

Dallas Retirement Village employees are expected to promote a healthy community culture for all residents and employees. This is a whole-person approach to health and wellness which includes eight dimensions of wellness: Emotional, Environmental, Health Services, Intellectual, Physical, Social, Spiritual and Vocational. Through these efforts we can ensure and exceed residents’ wellness needs relating to their mind, body and soul, which may also have a positive effect on the employees, as a result.

QUALIFICATIONS:

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  Medical Records Assistant must meet the following educational and experience requirements.

a. Able to meet the public and interact well with people (experience working with seniors preferred.)

b. Have a High School diploma.

2. Must be able to read, write, speak and understand the English language adequately to perform job duties.

3. Must be able to make independent decisions.

4. Must be knowledgeable of medical terminology.

5. Must be able to follow written and oral instructions.

Physical Requirements/Working Conditions:

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  Move throughout the building and grounds as needed throughout the day.
• Must be able to cope with mental and emotional stress of the position.
• Have good hearing and visual acuity.
• Have good verbal communication skills.
• Be aware that you may be exposed to communicable diseases, blood and body fluids that may contain HIV and/or HBV.
• Handle exposure to cleaning chemicals and/or offensive odors.
• Exhibit fine and gross motor activities such as pushing, pulling, lifting, bending, and kneeling.
• Is subject to frequent interruptions.
• Communicates with nursing personnel and other department personnel.
• Is involved with residents, family members, personnel, visitors, government agencies, etc. under all conditions and circumstances.