Summary

Files resident history and physicals, consultation notes, and clinical resumes in the resident’s health record. Maintains a log of admissions and discharges, room changes, absences (hospital family visit, etc.) and date returned. Checks charts for timely physician visits per Physician Services policy. Thins charts, transports to medical records, and prepares medical records for storage per the Medical Record Organization and Maintenance policy. Conducts chart audits for regulatory compliance and QAPI reporting. Mails orders to physicians for signatures. Sends discharge form to the appropriate physician at the time of discharge or death. Completes forms for insurance companies. Copies records as requested according to established policy. May be assigned other duties as appropriate.

Job Qualifications

• High school diploma or equivalent
• Certified Nurse Assistant preferred
• Healthcare experience in a long-term care setting with a working knowledge of medical terminology is highly desired
• Possesses integrity, initiative and loyalty
• Ability to concentrate on detailed work for extended periods of time