Hospice Medical Records Clerk

Maintaining Patient Files

Maintains and updates patient files in EMR. Completes chart admission audit and communicates issues/problems to the Clinical Director. Inputs/updates into current software system any information or changes relating to clinical status, insurance, level of care, staff assignment or discharge. Scans and files all clinical data, hand signed orders and consents into patient records.

Electronic Medical Record (EMR)

Ensures plan of care/comprehensive assessment update/recertification are opened in a timely manner to allow staff to document their summaries prior to IDG team meeting. Tracks certification statements/POC/CS recertification’s and physician orders after RN emails to med records. Runs unresolved order reports from admin console weekly to track unsigned orders.

Supporting Clinical Operations

• Contacts physician office, hospital or nursing facility in a timely manner in order to obtain current information, signatures or any other information pertinent to the patient’s admission and their hospice chart.
• Affords assistance with tracking and ordering durable medical equipment (DME) and medical supplies.
• Assists as needed with providing information necessary for annual report and other patient data which may be requested.
• Compiles visit logs from all staff and compares visit log to contact visit report weekly.

Team Meetings and Documentation

• Participates in Quality Assessment and Performance Improvement activities.
• If requested, participates in team meeting and is responsible for ensuring all documentation and charts are present as requested at team meeting.
• Responsible to maintain the team meeting sign-in sheet, and ensures that the team problem list is attached.
• Responsible for closing any paper records: clinical/bereavement charts, and preparing charts beyond thirteen (13) months so that they may be moved to off-site storage.
• Communicates with the Clinical Director in order that the charts are sent to off-site storage.

Administrative Duties

• Type’s letters, reports and other materials as requested.
• Answers the telephone in professional manner and channels the call accordingly.
• Interacts with other disciplines as needed to ensure support.