Medical Records/Business office Assistant

Medical Records

• Duties:
  • Maintain nursing/medical records mail log.
  • Maintain record of admits and discharges.
  • Prepare new charts for incoming residents.
  • Place ICD-10 codes and diagnoses on facesheet and cumulative diagnoses sheet.
  • Close out charts for discharged residents.
  • Maintain an organized filing system for resident records.
  • Ensure that doctors have signed all necessary forms in chart including P.O. forms - this will require both mailing of the documents and communication with the doctors periodically.
  • Audit each chart within 2 weeks of a new admit for necessary initial assessments (social services, dietary, activities, nursing).
  • Audit each chart periodically for necessary documents including nurse’s notes, monthly summaries, weights and vital signs, doctor progress notes and physicals.
  • Thin charts every three months and/or at discharge.
  • File medical records in resident charts.
• Telephone Orders:
  • Maintain MDS Records/Careplans.
  • Maintain stock of nursing forms at nurse’s station for use by staff.
  • Avoid assisting in keeping nurses station clean and organized.
  • Avoid assisting in responding to phone calls and family/resident concerns.
  • Avoid maintaining nurses station fax machine including the replacement of ink cartridges and adding paper.
• Other Duties:
  • Assist in keeping nurses station clean and organized.
  • Avoid maintaining nurses station fax machine including the replacement of ink cartridges and adding paper.
  • Avoid assisting in responding to phone calls and family/resident concerns.
  • Maintain nurses station fax machine including the replacement of ink cartridges and adding paper.
  • Avoid participating in quality assurance functions including but not limited to: Acting as secretary to the quality assurance committee including but not limited to keeping minutes, scheduling meetings, and sending meeting notices.
  • Participate in quality assurance functions including but not limited to: Acting as secretary to the quality assurance committee including but not limited to keeping minutes, scheduling meetings, and sending meeting notices.