Medical Records/ Central Supply (86723)

Primary Responsibilities

The Medical Records Coordinator will maintain and update the residents’ clinical records in a confidential, systematic, well-organized manner in conjunction with acceptable policies/procedures that include OBRA guidelines; Texas State Standards and Individual Nursing Home Standards. The Medical Records Coordinator will report directly to the Director of Nursing.

Essential Functions

• File documents in the appropriate records daily.
• Enter new admits and discharged residents in the Admission/Discharge Log daily.
• Track outgoing telephone orders and other documents pertaining to the resident.
• Thin the residents’ active charts daily by the census.
• Maintain tracking log for Progress Notes, Physician’s History and Physical.
• Send out monthly compliance letters to physicians and follow up bi-monthly on progress of visits.
• Communicate with Administrator, DON and Medical Director on the compliance of the physicians’ services.
• Maintain the Death Report and mail/fax to the State each month no later than the 10th of the month.
• Print the MARS/TARS and Consolidated Orders.
• Maintain and update Master Signature Legend.
• Audit new admits, re-admits and discharged residents’ records and report findings during the morning meeting.
• Maintain HIPAA log of requests for releases of information received pertaining to past or present residents of the facility.
• Complete monthly QA forms and participate in the QA and compliance meetings as required.
• Follow up on incomplete records daily.
• Check Completion of Discharge Summary.
• Close out discharged residents’ records.
• Maintain the Destruction Log for closed records.
• Box previous year closed records for storage.
• Order nursing department office supplies/forms and maintain availability at nurses’ station.
• Update forms in various locations as changes are made by the corporate Forms/Policy Committee.
• May be necessary to assist in the evacuation of residents during emergency situations.
• Actively assist and participate in the enhancement of the lives of our residents through our dedicated approach to patient care and our census-building program.
• Actively assist and participate in the development and retention of staff through; recruitment, training and nurturing the employees of the nursing home.
• Perform other duties and tasks as assigned by the Administrator or Director of Nursing in accordance to the qualifications and training