To maintain accurate records of patients admitted to and discharged from the Hospital. To maintain accurate daily statistical information.
STATUS: Part Time
LOCATION: Gouverneur Hospital
DEPARTMENT: Health Information Management
SCHEDULE: 8 Hour, Variable
ATTRIBUTES
High School diploma with major in secretarial courses.
Minimum of six months in a Medical Records Department is preferred.
Education in Medical Terminology is preferred.
When covering department alone on holidays, must meet demands of medical staff, nursing staff and other ancillary departments.
Keyboarding skills with previous computer knowledge preferred.
RESPONSIBILITIES
Checks in returning charts according to department procedure.
Accurately files patient record using terminal digit, service date, discharge date, etc., sorts and attaches loose reports to patient charts according to departmental policy.
Promptly retrieves, locates, and delivers patient records to requesting party, being mindful of any special instruction, and following departmental procedures.
Retrieves records from the Doctor’s Room, and processes according to departmental procedure.
Maintains “pulled for” box daily, verifying location of outguided records, making sure records are returned to the department by the day’s close of business, documents findings, and promptly notifies supervisor of any problems or concerns.
Maintains Master Patient Index (MPI) card file on a routine basis to locate any misfiles.
Receives Emergency Department records daily and accurately files them into permanent filing. For those patients without Terminal Digit folders, after double checking in computer, one is created, MPI card is created or updated, and then the folder and chart are filed into permanent filing.
Accurately files the contents of the “cart” into permanent filing.
Files down one month of “wall” records every month to maintain only previous and current month in main office.
Performs secondary analysis (quick check), updates incomplete record information in computer, prints a hard copy, places it at the front of the record, and distributes the record accordingly.
Refers individuals requesting information release (ROI – Release of Information) to Correspondence Clerk. Seeks guidance for emergency requests.
Receives, places, and transfers telephone calls. Handles telephone information requests with courtesy, accuracy and respect for patient confidentiality in accordance with department and hospital policy.
Maintains permanent file rooms; no boxes on floors, no loose charts or parts of charts left out and unfiled, shifts records as needed, death records promptly pulled, etc.
Communicates daily with Correspondence Clerk for chart pulls and copies charts promptly for Release of Information (ROI) requests; any problems or concerns are promptly reported to supervisor.
EDUCATION LICENSES/CERTIFICATIONS Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran
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