JOB PURPOSE:

Assumes authority, responsibility and accountability for the responsibility and accountability for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards and state and federal laws and regulations for long term care facilities. Establishes and implements policies to ensure that records are complete, accurately documented, and readily accessible and systematically organized. Collaborates with Nursing Home Administrators o allocate department resources in an efficient and economic manner to achieve department objectives.

KEY RESPONSIBILITIES:

1. Ensures that all clinical records contain sufficient information to identify the resident; a record of the resident’s assessments; the plan of care and services provided; the results of any preadmission conducted by the State, and progress notes.

2. Initiates and participates in the development of facility policies and procedures to ensure that medical records are complete, accurately documented, readily accessible and systematically organized.

3. Develops and implements record storage and retrieval system that complies with applicable record retention laws and maintains accessibility of records

4. Inspects closed records for completeness. Systematically organizes closed medical records for long term storage. Reports delays in completing records to Nursing Home Administrator.

5. Develops and maintains appropriate safeguards against unauthorized access and use of computer based medical records.

6. Evaluates medical records for and record format. Makes recommendations for change to continuously improve quality of facility records and records keeping practices.

7. Evaluates, through record reviews of open and closed records, compliance with medical record documentation policies. Reports findings to Nursing Home Administrator and Director of Health Services.

8. Develops and conducts educational programs for facility staff to explain and discuss documentation policies and practices. Provides training and staff development opportunities to ensure that staff can distinguish between confidential/non-confidential information and release information only in compliance with facility policies.

9. Maintains, updates and distributes the lists of facility approved abbreviations and definitions.

10. Provides access to all records pertaining to residents (including current medical record) within 24 hours of oral or written request of resident or legal representative. Makes copies available within 2 working days of request.

11. Develops and implements safeguards against loss, destructions, unauthorized aces or use of clinical record information including procedures to maintain confidentiality of all information contained in resident’s record and to obtain authorized consents to release information. Releases information without written consent or legal representative only when required by law.

12. Advises Administration, physicians, facility staff on applicable requirements regarding the control, use and release of clinical information. Advises administration on ways to safeguard confidentiality of medical records of facility staff.

13. Conducts periodic quality control assessments of staff implementations of medical records policies and procedures. Analyzed findings and develops, implements ways to improve performance.

14. Collects and displays clinical data requested by Administrations, facility committees, regulatory agencies, or accrediting bodies.

15. Participates in the developments of the department budget. Provides relevant financial information to Nursing Home Administrator regarding department financial needs and status.

16. Communicates with Nursing Home Administrator on daily basis to discuss medical record and budget issues. Recommends to Nursing Home Administrator numbers and type of personnel needed to meet facility needs in compliance with state and federals laws/regulations.

17. Actively participates in long term care survey process by instructing staff in matters of conduct and disclosure, maintaining a present at all times surveyors are on-site and directing the timely collection of information required by the survey team.

18. Demonstrates concern for identified problems and undertakes corrective action while survey is in progress if appropriate. Fathers and presents supplemental documentation to avoid potential deficiencies. Collaborates with Nursing Home Administrator to develop responses to survey report as needed.

19. Maintains current skills and knowledge through continuing educations. Applies information to job responsibilities. Performs other duties as assigned by supervisor.

KNOWLEDGE, SKILLS, ABILITIES:

1. Participates in center/agency surveys (Licensure/JCAHO) and any subsequently required reports.

2. Attends and participates in continuing educational programs to keep abreast of changes in your field as well as to maintain current license/certification, as required.

3. Attends and participates in mandatory in-services.

4. Honors patients/residents’ rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints.

5. Complies with corporate compliance program.

6. Reports job-related functions/tasks that involve occupational hazards including exposure to blood and body fluids and others as necessary.

7. Follows established safety regulations, to include fire protection & prevention, smoking regulations, infection control, etc.

8. Follows established safety procedures when performing tasks and/or working with equipment

MINIMUM EDUCATION REQUIRED:

High school diploma or equivalent.

MINIMUM EXPERIENCE REQUIRED:

A minimum of 1 year of experience as medical records practitioner in long term care facility

ADDITIONAL QUALIFICATIONS:

Preferred current certification as an Accredited Records Technician.

Certification as Registered Records Administrator preferred.

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As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.