Medical Records - River Crossing Rehab and Healthcare Center

Medical Records Reports To: Director of Nursing

Supervisers: Position requires no supervision of other staff members.

Medical Records Requirements: 

• Must have at a minimum a high school diploma or the equivalent.
• Must have at a minimum a limited ability to use computers.
• Must have understanding of chart and filing organizational systems.

Medical Records Duties:

·         Maintain nursing/medical records mail log.

·         Maintain record of admits and discharges

·         Prepare new charts for incoming residents

·         Place ICD-10 codes and diagnoses on facesheet and cumulative diagnoses sheet

·         Close out charts for discharged residents

·         Maintain an organized filing system for resident records

·         Ensure that doctors have signed all necessary forms in chart including P.O. forms –this will require both mailing of the documents and communication with the doctors periodically

·         Ensure that doctors perform annual physicals for each resident

·         Audit each chart within 2 weeks of a new admit for necessary initial assessments (social services, dietary, activities, nursing)

·         Audit each chart periodically for necessary documents including nurse’s notes, monthly summaries, weights and vital signs, doctor progress notes and physicals  

·         Thin charts every three months and/or at discharge

·         File medical records in resident charts

o   Telephone Orders

o   MDS Records/Careplans

·         Maintain stock of nursing forms at nurse’s station for use by staff.

·         Assist in keeping nurses station clean and organized.

·         Assist in responding to phone calls and family/resident concerns.

·         Maintain nurses station fax machine including the replacement of ink cartridges and adding paper.

·         Participate in quality assurance functions including but not limited to:

o   Acting as secretary to the quality assurance committee including but not limited to keeping minutes, scheduling meetings, and sending meeting notices.

·         All other duties as assigned by supervisor.