Medical Records Assistant
North Mobile NRC LLC
Prichard, AL
Job Title: Medical Records Assistant Effective Date: 8/1/2012
Department: Nursing
Supervised By: Medical Records Coordinator Supervises: N/A
General Description
The Medical Records Assistant is responsible for assisting in the preparation,
compilation, maintenance, storage and retrieval of medical records in a timely and
accurate manner.
Essential Duties
1. Conducts routine qualitative and quantitative audits. Report findings periodically and
as requested and assists with ensuring follow-up/corrections are completed.
2. Assists in the security of health information systems and medical records.
3. Initiates the in-house active and overflow files and prepare labels/forms in
coordination with the admission process.
4. Thin in-house records in accordance with written policy and procedure and file in
chart order for discharge in the overflow record.
5. Maintain the in-house chart appearance and organization.
6. File all incoming clinical information in the active and overflow charts on a daily
basis.
7. Prepare paperwork for discharge and assemble record in discharge chart order.
8. Support and assist in release of information as assigned by the Medical Records
Coordinator.
9. Participates in meetings and committees as requested.
Standard Requirements
1. Supports the Mission, Values and Vision of the Facility.
2. Is knowledgeable of resident rights and supports an atmosphere which allows for
the privacy, dignity and well-being of all residents in a safe, secure environment.
3. Supports, cooperates with, and implements specific procedures and programs for:
OSHA and safety, including universal precautions and safe work practices,
established fire/safety/disaster plans, risk management, and security, report and/or
correct unsafe working conditions, equipment repair and maintenance needs.
4. Adheres to:
a. Confidentiality of all data, including resident, employee and operations
data.
HISTORY:
(A) 8/2012
b. HIPAA regulations
c. Quality Assurance requirements and compliance with regulatory
requirements.
d. Compliance with current law and policy to provide a work environment
free from sexual harassment and illegal and discriminatory behavior.
e. Code of Conduct and Compliance Programs when performing job
functions
5. Supports and participates in common teamwork:
a. Cooperates and works together with all co-workers; plans and completes
job duties with minimal supervisory direction, including appropriate
judgment.
b. Uses tactful, appropriate communications in sensitive and emotional
situations.
c. Follows up as appropriate with supervisor, co-workers or residents
regarding reported complaints, problems and concerns.
d. Promotes positive public relations with residents, family members and
guests.
e. Completes requirements for in-service training, acceptable attendance,
uniform and dress codes including personal hygiene, and other work
duties as assigned.
f. Participates as assigned in the orientation of new staff and demonstrates a
positive, helpful, and enthusiastic attitude.
6. Immediately reports incidents of alleged resident abuse or neglect or alleged
violations of residents’ rights to Director of Nursing or Executive Director.
7. Knowledgeable of age specific developmental factors specific to adult and
geriatric residents (i.e. physical, cognitive and socialization factors) in planning
delivery of care.
8. Maintains current practice standards or changes by participating in educational
opportunities provided by the Facility and outside resources.
Other Duties
Perform tasks which are supportive in nature to the essential functions of the job, but
which may be altered or redesigned depending upon individual circumstances. Performs
other work duties as assigned.
Qualifications
Education/Training: Preferred credentialing as a Registered Health Information
Technician (RHIT). 12 months prior experience in medical records department preferred.
A.D.A.A.A ((Americans with Disabilities Act) as amended) REQUIREMENTS:
Must be able to bend, stoop, push, pull, and walk and stand for most of the working day.
Requires manual dexterity sufficient to provide hands-on care to residents as well as to
operate standard office machines such as fax, telephone, etc. Requires normal range of
HISTORY: