Medical Record Tech, Mon, Wed, Fri 9am-3:30pm, REQ 24012
Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report patient information for health requirements and standards. The Medical Record Technician must be able to perform all of the duties that a Medical Record Clerk performs and demonstrate and apply advanced medical record decision-making capabilities as required.
- Prioritizes and re-prioritizes work based on the changing needs of the customers, in communication with the HIM Director and or designated Supervisor.
- Reports all incidents in a timely and effective manner.
- Demonstrates organizational competency by completing reconciliation and productivity as outlined.
- Provides relief, coverage, and cross training for all Medical Record Clerical and Tech positions, as needed.
- Scans or archives records as appropriate.
- Collects and verifies via reconciliation all current and previous records of discharged inpatients and outpatients (sdc, wc, medcl, breast care, endos etc...) with days visits and notes status (inpt, unavailable, missing) within 24 hours from nursing units. Assembles component parts of inpatient and outpatient records according to policy and procedures ensuring all visits and documentation is accounted for; scans, indexes and quality checks all inpatient, outpatient charts, and Emergency Department charts on a daily basis. For delivery of special paper chart requests: Routine requests delivered within 20 min. if requested by nursing units.; STAT requests within 5 min. Inter-files all late-arriving reports & loose paperwork into the correct chart order or electronically as appropriate.
- Logs current discharges into Meditech chart tracking module, moves records as needed. Makes necessary corrections in medical record when appropriate.
- Signs out (logs in) all visits being analyzed in Meditech and returns (logs out) all visits upon completion. Returns & files charts either in paper form or electronic in appropriate location (Inc, Inpt stg., processing, perm, e-chart.).
- Reviews, researches, and exhausts all attempts to retrieve missing information from nursing units. Notifies HIM Director via email form of missing charts over 3 days.
- Reviews all requests for PHI, including continuation of care faxes and ensures that proper authorization to disclose the information has been received, as needed and fills the request. Handoff to ROI Specialists regarding returns of defective requests for PHI.
- Reviews each record for content of highly confidential information and handles appropriately.
- Opens department mail and logs in and out each request for Protected Health Information (PHI) into the Release of Information tracking system database according to policy and procedure.
- Responds to all telephone requests promptly and within a timeframe consist with the urgency of the request.
- Maintains the Release of Information tracking system database. Primarily: combining duplicate requestors, identifying problems with receivable functionality. Maintains error log.
- Maintains a current portfolio of all correspondence letters (past & present). Reports/suggests updates needed to HIM Director and/or designated Supervisor. Provides statistical reports to HIM Director on weekly basis or as requested.
- Responds to all routine written requests within seven (7) working days of receipt.
- Responds to all routine fax requests within 24 hrs. of receipt.Urgent or STAT requests within 10 min.
- Responds to all walk-ins seeking access to PHI as appropriate. Large requests allow at least 48 hours for processing.
- Meticulously reviews and prepares copies of medical records in response to subpoena and court order requests including coordination of certification signature and delivery to court. Reviews status of all pending subpoenas or court orders prior to any time off. Immediately notifies HIM Director and Supervisor of all subpoenas and court order requests prior to being filled.
- Refers any potential medical/legal issues to the HIM Director, designated HIM Supervisor, and to Risk Management as appropriate.
- Coordinates retrieval of images and copies microfilm and/or microfiche using microfilm equipment as necessary.
- Coordinates the photocopying of medical records with co-workers and others involved in copying assistance as needed.
- Investigates and verifies all MRUNs assigned by Registration staff the previous day to detect any duplicate MRUN assignments. If duplicates are found, merges according to protocol for both the MPI and patient's medical record.
- Reviews Medical Record Transaction Report daily and confirms, edits or corrects each new entry such as name spelling, format, SSNs, DOB changes as needed.
- Maintains quality improvement monitoring logs and reports (MPI Duplicate MRUN Log) daily, weekly potential duplicate and duplicate records reports. Compiles and organizes data for MPI Report. Provides monthly statistical reports to the HIM Director.
- Locates and retrieves duplicate related charts/paperwork housed in subground permanent file and/or offsite storage file and reconstructs hardcopy charts when necessary.
- Responds with timely communication regarding several departments throughout the organization (Patient Access, Scheduling, Birth Registrar, Lab, Blood bank, Pediatrics, Breast Care, Andover Surgery, HIM, EMPI and others).
- Maintains and emails detailed report of all documented duplicates merged on a monthly basis to designated department managers.
- Effectively communicates with MPI Coordinators at other Steward facilities on an as-needed basis.
- Performs internal audits for inpatient and outpatient medical records as directed by HIM Director as required by the Joint Commission.
- Retrieves medical records upon request for clinical review, audits, and assigned 'pull' lists according to policy and procedure.
- Fills medical record audit requests from regulatory and commercial auditing entities in a timely manner according to each request.
- Competent in transcription processes including: report search (Meditech EMR, Transciption Service software), filing, obtaining all information requested for STAT dictations and working with Transcription Service to ensure efficient processing of Transcribed reports and corrections are made timely within TAT requirements.
- Verifies the ADT on dictated reports and reports errors to the MT coordinator for correction. Handles PDOC error corrections as appropriate.
- Performs daily mailing and/or faxing of copies of transcribed reports and appropriate handling of failed faxes as per instructions from HIM Director.
- Assists physicians with transcribed or PDOC reports as needed.
- Demonstrates a thorough understanding and application of the Incomplete Records deficiency management module, HIM module, and ITS routines in Meditech.
- Performs inpatient and outpatient record analysis and completes process within five (5) days or less of discharge. Tech enters data noting record variations/omissions for each appropriate chart in the chart deficiency module and applies deficiencies as appropriate on inpatient, outpatient, and emergency department medical records according to policy.
- Coordinates physician notifications and sends notification letters regarding weekly physician suspensions according to 30-day delinquent policy and HIM procedure checklist.
- Locates and retrieves incomplete records and contacts physician office managers and physicians weekly to make arrangements for reports and orders to be signed and/or completed and assists physicians with the completion of his/her incomplete records as needed.
- Maintains physician scheduled appointments or absences with HIM, tracks vacations and records incomplete visits per policy.
- Provides orientation to new physicians in the record completion process as needed.
- Follows CPOE procedures for unsigned orders including changing deficiency status as needed.
- Demonstrates the ability to instruct physicians on electronic record process including electronic signature.
- Notifies HIM Director of problematic charts for presentation to Medical Records Committee.
- Assists in conducting incomplete file audits as often as needed.
- Compiles and submits weekly statistical report on incomplete record status to HIM Director. May be asked to assist with monthly delinquency rate report.
Required: Two years recent medical record experience working in an acute care Health Information Management department processing and analyzing hybrid or electronic records to include scanning and indexing medical records into an electronic EMR system. Completion of an Associate's Degree in Health Information Management CAHIIM accredited program or RHITcredential preferred. Medical terminology knowledge preferred. Strong organizational skills with ability to work in fast-paced, multitasking, productivity oriented environment required. Excellent Interpersonal/communication and customer service skills required. Meditech experience preferred.