Medical Records Personnel

• Maintain complete and accurate medical records in compliance with the rules and regulations of all regulatory agencies and the standards of excellence promoted by the American Medical Records Association.
• Maintain and keep current the Admittance Log Book.
• Assemble and complete all new charts with resident assigned medical records number, name, physical name, or any other information pertinent to the resident.
• Maintain resident charts according to Medical Records Procedure Manual to meet regulations and to ensure ease of handling, and reports deficiencies to Director of Nursing / Assistant Director of Nursing.
• Establish and maintain a chart alphabetical filing system for both current and discharged residents in the medical records office.
• Follow procedures established in Medical Records Procedure Manual for releasing resident information.
• Handle discharged residents’ charts as outlined in medical Records Procedures Manual; monitor for uncompleted records or notes; notify Director of Nursing, or appropriate department head, of any deficiencies.
• Enter all necessary information in the “Death Registry” when a resident expires. Obtain a copy of the death certificate and file with the residents’ chart.
• Maintain master inventory list at par levels and current costs, updating as needed; monitor par levels with Nursing Unit Usage.
• Conduct daily inventory count of all supplies storage areas.
• Upon arrival of delivery of supplies, making sure quantities received, match packing slip.
• Maintain nursing supplies, place delivered supplies in appropriate storage area, and apply charge tickets.
• Review and code as needed all residents charges daily. Forward charges to Business Office.
• Keep all supply storage areas neat and orderly.

• Ability to effectively communicate with residents, families, and all levels of staff.

Clover Healthcare