Casa Bonita Conv. is looking for an exceptional and experienced Medical Records Supervisor. This individual compiles and maintains medical records of patients of health care delivery system to document patient condition and treatment.
The Medical Records Director is responsible for all the tasks performed in the Medical Records Department.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
· Complies with the facility’s attendance policy requiring regular, reliable, and punctual attendance
· Maintains daily admission and discharge log for each resident
· Prepares charts for admission with chart order form in front of chart.
· Checks charts on new admissions daily until all below required paperwork has been completed:
o Admission records is completed and on the chart;
o Resident’s Rights are signed;
o Inventory of personal effects and valuables is completed and signed;
o History and physical is on the chart (documented within 72 hours). If resident is transferred from an acute, call the acute hospital to send a copy of the H&P. If H&P is over five days old, this must be updated. If copy of the H&P is not signed, flag for doctor’s signature;
o Self-admission of medication on admissions;
o TB screening done or evidence that it was done within the past 90 days (copy of chest x-ray from the acute);
o Admission orders are received and included: diet order, functional status order, medications/treatments required, and orders for safety;
o Discharge planning recorded within seven days;
o Consent for treatment properly signed and witnessed;
o Rehabilitation potential documented on H&P and face sheet;
o Statement from physician as to whether or not he has advised the resident of their condition on H&P;
o Activity plan recorded within seven days;
o Social Service Evaluation documented within seven days;
o MSD face sheet on admission;
o MSD assessment completed within 14 days.
· Prepares all charts with tabs following chart order sequence.
· Assists with paperwork on new admissions.
· Prepares all forms in the chart with resident identification information.
· Assembles and audits discharged residents’ records.
· Prepares daily audits, admissions, telephone orders, change of condition, and Medicare documentation.
· Prepares audits and distributes to Administrator and DON.
· Reviews census daily for resident admission status.
· Mails forms or maintains a mailbox for physicians at facility to ensure completion of required documentation, such as the discharge summary or progress notes.
· Documents each discharge in the discharge analysis/discharge log.
· Completes Death/Mortician Receipts on all deaths.
· Maintains daily filing for in-house, overflow and discharge charts.
· Audits the thinning/overflow resident charts, and completes and files. Assures overflow files are maintained in the order of the discharge resident’s record.
· Maintains physician monthly control log.
· Answers correspondence regarding the release of information, following facility policy and procedures on “Release of Information.” Refers all subpoenas to Administrator.
· Assists with paperwork on discharges, transfers, and expirations.
· Mounts laboratory x-ray reports after the nurse has initialed them.
· Records the lab and x-ray reports in the lab book as having been returned.
· Checks the physicians’ orders daily for signatures and new orders that need signatures and flag them.
· Checks orders for the proper notation by nursing staff.
· Keeps charts and nurses station supplied with blank forms as needed.
· Creates admission packs for each unit station to include all necessary forms.
· Maintains/organizes for efficiency and accessibility of record keeping and management.
· Audits charts weekly for medication, treatment, pressure sores and reports result to DON and
· Monitors completion of medical records in accordance with time standards.
· Monitors the Resident Care Plan and updates at the IDT Conference.
· Checks charts weekly for:
o Weekly licensed summaries
o Daily charting on Medicare residents, acutely ill residents, residents involved in a fall/incident
o Proper documentation of medication-treatment records
o Weekly evaluations of decubitus or other conditions being treated
o Doctor’s visits are timely, orders are renewed and progress notes are written
o Correlation between orders/treatments administered
o Residents with Foley catheters require:
¬ An order for the catheter to remain in;
¬ Bladder assessment done within 14 days;
¬ Weekly summaries of the I&O by licensed nurse for 30 days;
¬ A 30-day re-evaluation as indexed on the PCP, MDS, and week summary.
· Updates disease index and physicians control log monthly.
· Checks weights for fluctuations (recorded the first week of each month) and ensures weight gain/loss is reported to the physician and documented.
· Prepares monthly audits for weight, pressure sores, RNA, psychotropic and restraints.
· Prepares computer sheets on scheduled dates for physician recaps and inputs physicians’ orders via the Medical Records Accu-Care computer system.
· Operates computer to process, store, and retrieve health information.
· Completes recaps on timeline agreed upon by Director of Nursing.
· Completes audit schedule each day, week, and month.
· Audits charts to ensure that:
o Bowel and bladder evaluations are done/updated for incontinent residents;
o Activity plan is updated quarterly and if change of condition occurs;
o Social Service progress notes are written quarterly and if change of condition occurs;
o Discharge planning is updated quarterly and if change of condition occurs;
o Nutritional assessment is updated quarterly and if change of condition occurs;
o Diagnoses are updated on the computer order sheet in agreement with physician’s documentation and correlation with medications.
· Participates in the Quality Assurance Program and Utilization Committee Meetings, and passes CQI.
· Follows up on all consultant/QA recommendations.
· Utilizes medical records procedure manual as needed.
· Responsible for maintaining up-to-day inventory of facility forms.
· Attend mandated meetings: daily standup, weekly PPS, and monthly triple-check.
· Performs other duties or functions as assigned by the Administrator.
Supervises Medical Records Assistant if applicable.
-Medical/Dental/Vision/401K Match (full time)