Performs assignments to assure all security and maintenance of the medical record. Must exhibit sound judgement and diplomacy when interacting with all requestors and/or authorized users of Protected Health Information. Must adhere to all hospital, state and regulatory requirements as well as departmental standards. Assignments are: ? Confirms receipt of medical information of all patient types. Reviews for completeness, enters MD deficiencies and assists with coordination of MD chart completion. Performs MD communication and follow up as described in the Medical Staff Rules and Regulations –Medical Record Documentation. ? Performs document imaging activities (chart preparation, document scanning and indexing), achieving timely availability to authorized users as well as accuracy and productivity standards. ? Maintains HPF queues to assure accuracy in the workflow process. Demonstrates proficiency in diagnosing hardware/software issues to guarantee no loss of data or workflow slippage. Reports problems when required to Information Services according to policy and procedure. ? Exhibits knowledge and expertise in medical record data maintenance as it pertains to regulatory requirements, i.e., state/federal requirements, CMS and other regulatory agents. Completes required documentation and submits according to meet and/or exceed individual agency requirements. Performs quality audits as assigned to assure integrity of the medical record. ? Demonstrates thorough knowledge of rules and regulations regarding privacy rules and release of protected health information with no reported breaches of confidentiality.
High school graduate. One to two years experience in a medical office setting.
CPR is required for any RN, LPN, PCT, Patient Transporter or other direct patient care provider. Emergency Department, Intensive Care Units, PACU, Medical Emergency Team and Anesthesia require ACLS. Pediatrics, SICU, Emergency Department and Medical Emergency Team also require PALS.