Medical Records Clerk

POSITION SUMMARY

• Under the direct supervision of the Medical Records Director or other designated manager, responsible for the maintenance of health records;
• organizes and maintains a system of files and records concerning patient diagnosis, treatments, admissions, discharges and daily patient census changes;

exercises good judgment, and functions independently. Utilizes electronic medical record system as applicable throughout the scope of duties and responsibilities.

DUTIES / RESPONSIBILITIES

1. Ensures confidentiality of all medical records information and completes forms for release of information. Refers to supervisor any requests of questionable nature.

2. Performs clerical / technical duties within scope of position classification :

a. Maintains a Daily Count Log.

b. Provides assistance related to medical records and transfers of offenders from institution to institution, incoming and outgoing.

c. Makes copies of medical records as instructed by the Medical Records Director.

d. Pulls, files and sorts medical records daily as needed.

e. Answers telephone, relays messages and transfers calls as appropriate.

f. Files loose documentation generated from inside and outside institutions.

g. Maintains file system for medical records.

h. Performs data entry of patient information for offender data into Offender 360.

i. Utilizes Offender 360 to send offender call-passes within the facility.

j. Maintains ffurlough logs as requested

k. Reviews charts for Department of Corrections Administrative Directive requirements.

l. Retrieves and sorts mail.

m. Thins medical records as necessary or as directed.

n. Assists with getting records to correct persons for health status reviews.

o. Without providing opinions, responds to inquiries regarding information contained in the medical record as directed by the Medical Records Director.

p. Copies, retrieves or organizes pieces / parts of the medical record for the clinical providers as requested.

3. Creates patient’s charts as needed.

4. Refers all clinical decision making to clinical staff or immediate supervisor and at no time acts to provide clinical opinion, clinical decisions or clinical direction to patients.

5. Upon receiving the necessary training and / or instruction, perform other duties as required

JOB REQUIREMENTS

The following requirements list the minimum to qualify. An equivalent combination of education and experience may be accepted.

LICENSING : None Required

CERTIFICATION : None Required

EDUCATION : High School Diploma or equivalent.

PREFERRED EXPERIENCE : Proficient in the use of copying equipment. Prior experience with use of electronic medical record system.

EOE / M / F / D / V

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