Health Information Associate

Job Responsibility - Chart Preparation and Scanning

• Validates receipt of all inpatient/ambulatory day surgery/emergency department patient records.
• Reviews medical records for poor originals, patient identification, and groups documents in proper order.
• Scans records into CDPI and maintains daily workflow.
• Retrieves discharged patient records, checks daily logs, and stamps poor originals.
• Prepares documents by removing staples, paper clips, sticky notes, and rubber bands.
• Groups like document types, places them in date sequence, and ensures correct patient identifiers.
• Copies damaged documents and removes COLD fed documents.
• Assembles documents in order and cleans scanner weekly.
• Assigns batches to the correct work queue and writes batches to the appropriate queue.
• Maintains appropriate scanner setup for optimal image results.

Job Responsibility - Quality/Validation of Scanned Documents

• Ensures high-quality scanning of patient records and loose documents.
• Indexes documents to the correct patient and document type.
• Positions documents correctly and verifies bar-coded documents.
• Splits and merges documents as necessary and maintains date order.
• Writes indexed batches to the appropriate queue and reviews work queues daily.

Job Responsibility - Chart Deficiency Analysis

• Reviews discharged patient records for incomplete or missing items.
• Identifies responsible practitioners and links deficiencies to appropriate physicians.
• Assigns deficiencies to physicians and maintains analysis turnaround time.
• Monitors reanalysis queue and reassigns deficiencies as needed.
• Verifies physician dictation and provides assistance to ensure compliance with chart completion policy.
• Maintains incomplete record rate and generates physician notification letters.
• Provides weekly reports on incomplete records and physician fines/suspensions.

Job Responsibility - Birth Certificate Completion/Submission

• Collects and submits live birth and fetal death data to NY State Department of Health’s Bureau of Vital Statistics and local Registrar.
• Enters data into SPDS computer database to generate and print birth certificates.
• Distributes certificates to appropriate obstetricians for signing and mails them to the local registrar within 5 days of birth.
• Files electronic birth certificates and handles error corrections.
• Completes fetal death certificates and forwards them to the Bureau of Vital Statistics within 72 hours of death.
• Attends educational sessions to stay updated on processes and regulatory changes.

Job Responsibility - Release of Information

• Reviews and processes requests for release of information for walk-ins and physician offices.
• Date stamps requests and verifies accuracy of requested information.
• Accesses computer applications to obtain demographic and visit information and enters requests in ROI software.
• Orders records from offsite storage and contacts ancillary departments for records.
• Responds to telephone calls and faxed requests from patients, physicians, and other healthcare providers.
• Affixes paternity affidavits to completed birth certificates and submits them to the local registrar.
• Completes and forwards original copies of fetal death certificates to the Bureau of Vital Statistics.

Job Responsibility - Skilled Nursing Facility (NDH Employees only)

• Verifies receipt of SNF discharged charts by reconciling the monthly census.
• Completes record assembly and analysis of SNF charts in accordance with state requirements.
• Notifies providers of incomplete records and assures all SNF charts are filed complete in accordance with state requirements.