Medical Records Director

The primary purpose of your job position is to assure that medical records are maintained in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained.

Delegation of Authority

As Medical Records Director, you are delegated the administrative authority,

responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Duties and Responsibilities

Administrative Functions

Assist in planning, developing, organizing, implementing, evaluating, and directing the medical records section in accordance with established policies and procedures. (Includes department policies and procedures, job descriptions, etc.)

Assist in establishing procedures to be followed in the collection, coding and indexing, and the filing / retrieving of medical records.

Advise the administrator on federal and state laws concerning medical records.

Review discharge and death records, as well as records on the nursing units.

Review department policies and procedures, at least annually, and participate in making

recommended changes.

Collect, assemble, check, and file resident charts and personnel records as may be necessary.

Ensure that incomplete records / charts are returned to nursing service for correction.

Assist in developing procedures to ensure records are properly assembled, coded, signed,

indexed, etc., before filing.

Ensure established policies and procedures for the medical records section are followed by all personnel.

Equipment and Supply Functions

Report equipment malfunctions or breakdowns to your supervisor as soon as possible.

Ensure supplies have been replenished in work areas as necessary.

Ensure that work / assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.

Ensure that MDSs are on file for hazardous chemicals used in the department.

Resident Rights

Maintain confidentiality of all pertinent resident care information to assure resident rights are protected.