The primary purpose of your job position is to assist the Medical Records Department, Charge and Staff Nurses in their day-to-day recording and charting of medical or administrative information in accordance with federal, state and local standards, guidelines and regulations that govern medical records, and as may be required by the Director of Nurses to ensure that the medical records are maintained in an informative and descriptive manner.
Major Duties and Responsibilities
- Operate personal computers to complete record keeping requirements.
- Develop a thorough understanding of the health care software and word processing software used throughout the facility to maintain resident records and meet charting requirements.
- Record medical and administrative information in accordance with established charting and documentation policies and procedures.
- Release information in accordance with established policies and procedures.
- Type, file and distribute correspondence as necessary.
- Answer telephone, page calls, deliver messages to residents and staff as necessary.
- Prepare charts and forms for new admissions, transfers and discharges.
- Complete necessary medical and administrative records upon resident’s admission, transfer or discharge.
- Deliver flowers, mail, etc. to residents as necessary.
- Notify Charge/Staff Nurse if a resident should be discharged without a physician’s order.
- Forward completed charts of discharged residents to the archive room once complete.
- Report to the Unit Director discrepancies found in transcribing physicians orders.
- Assist in arranging for and making appointments for diagnostic and therapeutic services.
- Keep nursing personnel informed of resident’s appointments.
- Review medical records for completeness of information, accuracy in the transcription of physicians orders, legibility, etc., as directed.
- Maintain an up-to-date roster of residents on your unit.
- Record appropriate resident information, identification data, etc. on designated medical records, wristbands, ID cards, bed and door tags, etc., as required.
- Direct visitors to resident rooms, office areas, etc., as necessary.
- Maintain a current list of emergency phone numbers for your unit.
