|Performs a variety of functions related to the incomplete chart deficiency system. Assembles and analyzes all types of records to ensure completeness, accuracy, and compliance with rules and regulations of the medical center. Responds to physician inquiries, retrieves medical records for physician completion and supports the physician suspension cycles. Required to perform a variety of functions related to the maintenance of medical records, including: retrieval, filing of charts and loose material, purging, and record requests. Performs reception desk functions, preparation of birth certificates, merge process, discharge processes, monitors and processes transcription for prompt delivery of reports to record and pt care areas, scanning/ electronic archiving of charts into electronic health record, enters charges for emergency department daily, and supports the billing company for the emergency room physicians. Responds to Correspondence requests from patients, physicians, insurance companies, attorneys, and other requestors of medical record information. Ensures that the disclosure of patient information is only permitted after written authorization from the patient /or court order. Abides by all State and Federal statutes as it applies to the release of confidential medical record information. Monitors the accuracy and integrity of the deficiency module for suspension process. Coordinates the retrieval, review, and scheduling and/or mailing of warning and suspension letters. Applies appropriate technical knowledge and methods to complete work assignment according to instruction and departmental/medical center policies and procedure. Supports and exemplifies the hospital established Achieving Exceptional Care standards.|
1. Performs a variety of functions related to the maintenance of the medical record including: assembly and analysis of all types of records of records to ensure completeness, accuracy, and compliance with regulation and policies, record retrieval from various areas and filing of records, their components and loose material. Provides physician assistance with incomplete records, updates delinquencies and suspension lists as needed. Completes birth certificates and submits to state. Completes requests for information following state and federal statues.
- Accurately and efficiently assembles medical record documentation in correct sequence according to established chart order, ensuring all loose material/EKGs, Health Care Proxies, etc are incorporated into chart at time of assembly.
- Identifies physician deficiencies accurately and efficiently, and update this analysis within computer system.
- Maintains or exceeds productivity standards for assembly and analysis
Inpatient: 4-5 per hour (excluding newborns)
Newborns: 8-10 per hour
OBS/SDC/Minor Px: 8-10 per hour
Norcap: 20-25 per hour
Emergency: 50-60 per hourRecords accurate productivity statistics on a daily basis and submits them to manager at the end of each week.
- Ensures that 100% of charts are received and processed within established timeframe from receipt of record.
Inpatient: within 1- 3 days of discharge
OBS/SDC/Minor Px: within 1- 3 days of discharge
Norcap: within 1- 3 days of discharge
Emergency: within 1- 3 days of discharge
- Ensures all discharged charts are received and any missing charts are found in a timely manner/alerting supervisor of any missing charts.
- Creates new patient record jackets as needed, following established department procedures.
Accurately and efficiently files completed medical records in terminal digit order on a daily basis.
- Responds to physician inquiries regarding record completion requirements in a professional and informed manner.
- Supports the suspension process by providing assistance to physicians as needed.
- Accurately updates suspension list as indicated; distributes modified suspension list to pertinent departments via e-mail process
- Locates all records on physician pull sheets as evidenced by records found and checked off on pull sheet. Pull sheets are filed alphabetically on a daily basis.
- Interfaces with medical staff and assists in record completion activities including explaining the department’s policies and procedures related to record completion.
- Exhibits diplomacy and tact when dealing with the medical staff so as to maintain a positive working relationship.
- Accurately and efficiently updates deficiency system (final check) to reflect record completion activity within 24 hrs. of physician visit.
- Demonstrates an understanding of record completion requirements as evidenced by accurate assessment and assignment of record deficiencies.
- Generates and distributes Notification/Warning/Suspension Letters to practitioners according to established schedule and departmental process.
- Communicates warning/suspension information to responsible Department Chair, Places courtesy calls and emails to physicians going on suspension and keeps a log of these calls.
- Completes Surgical M&M process, assists providers with process.
- Accurately and efficiently sorts and mails out cc or failed faxes daily.
- Record retrieval for ED and inpatient encounters are completed within 10 minutes of request.
Retrieval rate of not less than 99% is maintained and records are delivered to respective areas.
- Sorts and consolidates all available loose medical record filing; rough sorting, fine sorting in terminal digit along with filing into patients visit associated with material.
- Pulls and delivers all medical records needed for all Nursing units, including all scheduled outpatient and Surgical Day Care procedures, including Pre-admit testing.
- Prepares medical records leaving the department by ensuring documentation of all previous encounters are in the chart; fastens loose reports into appropriate chart order.
- Electronically and physically transfers all medical records to the appropriate location within dept and within computer location sign-out application, updates location when moving charts.
- Prepares and logs fetal monitor strips for storage at an off-site storage facility.
- Transport all discharged charts from Units and electronically signs them out to proper areas, including any old volumes.
- Ensures all discharged records have all loose material drop filed with them prior to going to assembly and analysis area.
- Ensures all discharges have facesheets
Files a minimum of one-inch per filing hour of loose medical record reports into permanent file, ensuring the name on the report matches the name on the medical record jacket.
- Productivity standard measurement: 1 inch per hour
- Routinely performs file maintenance on assigned filing digits to include:
• Checks for misfiled records to ensure file integrity
• Consolidates all loose medical record components located in outguides and temporary folders and incorporates into the permanent medical record when it becomes available.
- Sends death charts to offsite storage facility per department policy.Files 100% of medical records in assigned filing digits before the end of each shift to facilitate future record retrieval.
- Productivity standard measurement: 60 per hour, this includes shifting of charts.Locates and retrieves 100% of medical records requested for patient care, special studies, release of information, research and administrative purposes and tags each visit to be reviewed.
- Maintains Organized File on all Non-patient care requests, including dates received and notes the dates pulled on each request and checks off each chart pulled.
- Ensures all charts for Audits, special studies and non-pt care requests are signed out to appropriate locations.
- Ensures that all Non-pt care pulls are completed within 72 hrs of receipt or HIS supervisor is notified of any issues.
- Performs audit of all records signed out to the Audit Areas to ensure a current status at all times, reminder call is made to requestor after 1 week, and charts are refiled 2 days after call if not reviewed by requestor, unless other arrangements has been made.
- Assists customers in completing authorization forms for release of information by asking questions to clarify information needed and providing dates of service.
- Includes asking for proper identification of patient and signature on forms prior to release.
- Accepts subpoenas after verifying that all pertinent identifying information is provided according to HIS policy; checks and cash must be submitted immediately to supervisor.
- Responds immediately to Advance Directive requests from floors and files any received Advance Directives or Health Care Proxies into chart as STAT filing.
- Electronically and physically merges medical records on patients who have been assigned multiple hospital numbers, after careful consideration of supporting demographic information.
- Prepares birth certificates and related verification, paternity and acknowledgement forms in accordance with state guidelines, using the Electronic Birth Certificate system; ensures notarization of related documents as required.
- Accurately and efficiently performs discharge processing functions to include: receipt of discharge records from nursing units and offsite clinics, matching up documentation to corresponding permanent medical record, electronically and physically transfers records to appropriate DAY location/folder.
- Scans, indexes, archives records as appropriate and within established department time frames.
- Daily generates ED Visit Log used to verify the receipt of ED documentation and other ED reports to ensure receipt of 100% of ED medical records in a timely manner.
- Generates data sheets and dictation by ED date of service and matches to corresponding ED medical record, sends appropriate information to ED Provider Billing Company.
- On daily basis: Gathers ED admission information, dictation, and charge tickets for coding staff and seeks out those missing. Files ED charts daily.
- Reviews all ROI requests and authorizations to ensure validity and Sends special authorizations to patients whose records contain privileged (sensitive) information as defined by hospital policy.
- Electronically logs requests for medical record copies in the Correspondence module of the Meditech system and
- Performs follow up on pending requests on a weekly basis
- Demonstrates knowledge of State and Federal statutes regarding release of information, as evidenced by accurate and appropriate response to subpoenas.
- Pulls and sends requested information following established guidelines for release of information and responds to urgent request for medical information received via fax in a timely manner. Off-site requests must follow HIS policy for retrieval and returns.
- Turn-around time for answering ROI requests is within 10 working days of receipt.
- Records are certified within 24 hours of completion.
- Contacts CGSMC Risk Management Department and legal counsel when cases require special handling.
- Daily filing and/or retrieve ancillary requisitions/orders in monthly boxes received from departments
- Perform Name change edits within computer system and on physical records.
- Enters charges accurately from charge tickets
- Enters charges within timelines established by facility
- Works Meditech reports daily for charge reconciliation and rejections, locate any missing charge records daily and tracks those awaiting provider completion.
- Supports physician billing company in all aspects of chart submission.
2. Applies appropriate technical knowledge and methods to complete works assignments according to instruction and departmental or hospital policy and procedures and demonstrates a working knowledge of the computerized patient registration systems, including chart locator and department module of Meditech, as required for prompt accurate retrieval and location of patient records and/or patient information.
- Demonstrates ability to use computer systems and analytical tracking skills to locate and retrieve medical records requested for patient care, release of medical information, research, and administrative purposes.
- Demonstrates ability to scan charts as applicable.
- Demonstrates ability to utilize various computer applications that stores/retains parts of record.
- Demonstrates ability to electronically sign out and/or move medical records being transferred from one location to another, to include records being transferred to other hospital departments as well as other units within the HIS Dept.
- Demonstrates clerical number identification and color recognition for records filed by number and color coding
- Demonstrates ability to monitor and use EMON application while appropriately processing transcription requests or delinquencies within chart. Can identify requested dictation, determine status, print and/or follow up on requested reports and print E-signature lists.
- Demonstrate ability to instruct physicians on electronic record process including electronic signature.
3. Hospital-Wide Responsibility: Employee is available and prepared to work during scheduled working hours to facilitate the smooth and efficient operation of the department and to meet approved staffing levels. Has knowledge of safety standards.
- Arrives at work on time, promptly, and works scheduled hours and days.
- Uses earned time appropriately, requests time off in advance, calls Supervisor to explain unscheduled absence according to department policy
- Punches in and out on time without trends of tardiness or leaving early identified via Kronos punch times, utilizes Kronos exception form for missed punches and record time off.
- Consistently maintains work schedule and adheres to facility policy on absenteeism.
- Observes proper time limits for lunch/supper and breaks
- Completes mandated education requirements for safety training, disaster training, Emergency codes, and any other assigned training for facility and department.
4. Strives for excellence in customer service and work performance. Supports and exemplifies the hospital established Standards of Behavior: Respect, Communication, Compassion, Teamwork and Accountability and the Pillars of Achieving Exceptional Care: Mission, People, Quality, Service, Growth, and Finance.
- Greets visitors courteously and promptly.
- Speaks clearly and provides accurate, understandable information.
- When required, provides interpreter for non-English speaking patients and/or visitors.
- Seeks assistance in matters requiring administrative/medical judgment.
- Maintains calm demeanor in stressful situations.
- Refers patients/families to appropriate services in area as needed.
- Anticipates routine information needs such as who to contact for additional information.
- Answers questions within scope of authority, forwards calls, or locates resources to solve problems.
- Limits unnecessary conversation in order to avoid distracting co-workers and customers.
- Responds to complaints quickly and initiates resolution or refers to source who can resolve problem.
- Observes patient’s right to confidentiality in all handling of medical information.
- Answers telephone calls within three to five rings and is clear, courteous and helpful. Uses appropriate departmental greeting. Places receiver gently back on unit after call is complete.
- Does not leave caller on hold without explanation.
- Responds to routine requests about departmental services by providing information via telephone or printed materials.
- Obtains all pertinent information accurately from the caller (i.e. name, relationship, telephone number and time of call).
- Screens calls appropriately (i.e. uses good judgment in determining when to locate and inform staff immediately or leave a message).
- Forwards misdirected calls to correct department/person.
- Displays hospital ID badge above waist at all times and observes hospital’s standards of conduct.
- Completes required safety training sessions and/or reviews materials for fire and disaster procedures provided by the hospital annually.
- Is flexible, accepts special assignments.
- Takes initiative by reporting problems and suggesting improved procedures to streamline and efficiency to department.
- Requests increased responsibility, occasionally taking on duties other than those assigned.
- Appropriately prioritized requests for assistance and other activities which contribute to the smooth operation of the department.
- Cheerfully assists physicians and customers
- Keeps work environment free of clutter and in a professional office appearance.
- Employee follows facility dress code at all times
- Attends and actively participates in regularly scheduled departmental team meetings. Read email every scheduled shift.
- Supports management team decisions.
- Builds and maintains good working relationships in own and other departments.
- Assists departmental budget goals by maintaining an efficient and effective level of productivity while working unsupervised.
- Performs duties as assigned as evidenced by work being complete when reviewed.
- Willingly accepts any Health Information Services tasks assigned by Supervisors/Director without the need for follow up.
- Avoids negative confrontations and arguments while seeking resolution to problems.