MEDICAL RECORDS ASSISTANT

ESSENTIAL JOB FUNCTIONS:

 

• Transcribe, accurately, physician and nursing orders on appropriate documents in a timely manner

 

• Keys information into computer systems, including EMR

 

• Assure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as required

 

• Record accurate, legible information about resident care and condition in appropriate sections of resident’s records

 

• Follow facility policies and procedures including those related to infection control

 

• Capable to perform new duties as assigned and trained

 

• Maintain resident medical charts, station documents and supplies

 

• Input physician and nursing orders to computer

 

• Establish and maintain effective communication both written and verbal

 

• Able to interact effectively with individuals who are cognitively and/or physically impaired

Revision Date: 03/01/14                                                                                                                                                    1               

 

• Organize nursing stations and maintain a tidy work environment

 

• Perform chart audits as assigned

 

• Demonstrate ability to maintain confidentiality of resident and facility information

 

• Prioritize workload and complete projects accurately and in a timely manner

 

• Assist with preparation for state inspections as directed.  Attend survey training and interact with state surveyors as directed by immediate supervisor

 

• Demonstrate interpersonal skills that contribute to a positive work environment

 

• Demonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactions

 

• Provide excellent service to staff, visitors, and residents

 

• Answer telephone professionally and in accordance with facility policy

 

• Demonstrate competence in use of proper body mechanics for both upper and lower body

 

• Monitor physical environment for safety or fire hazards and corrects or reports potential problems immediately to Charge Nurse.  Promptly reports housekeeping and maintenance problems to Charge Nurse

 

• Report injury to resident or self to Charge Nurse immediately

 

• Participate in fire and disaster drills.   In the event of any emergency, carries out assigned duties to assure resident safety

 

• Knowledge of emergency and disaster procedures of facility.  Able to locate nearest exit, to understand and respond to written or oral instruction in case of emergency

 

• Adhere to policies and procedures

Qualifications

QUALIFICATIONS/REQUIREMENTS:

Education:                           High School graduate or equivalent 

 

License:                                None Required

 

Work Experience:               Previous experience in medical records preferred

  

Language Skills:

• Must be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language.  

 

Mathematical Skills:

• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to perform these operations using units of weight measurement, and volume.

 

Communication Skills:

• Must have exceptional communication and customer service skills, and be empathetic.  
• Ability to effectively communicate with patients, families, responsible parties, staff and outside resources and agencies.