Job Description

Job Title

Responsible for preparing, assembling, scanning, indexing, and analyzing inpatient, outpatient, and/or ancillary records, ensuring all charts are accounted for and completed. Assignments are planned and executed with considerable independence in compliance with established policies and procedures, bylaws, regulations and laws.

Reports To: HIM Director

Qualifications

Two years experience in a healthcare setting preferred.

Responsibilities:

• Responsible for copying, sorting and mailing dictation to surgeons, referring physicians, and anesthesiologists as requested.
• Organize, assemble and analyze medical records for completeness ensuring all components of the record are present and in order.
• File completed medical charts and any loose information relating to old charts.
• Respond to information requests from patients, physicians, billing department and nursing staff.
• If documentation is missing, return chart to the nursing staff to correct.
• Deliver charts that need to be completed by nursing staff to either Pre-Op or PACU.
• Disassemble, scan and flag all deficient charts. Once signed, verify chart is complete before sending to the permanent file.
• Review operative report to verify the surgeon has dictated the radiology findings for any case in which radiology was used.
• Disassemble medical charts for discharged patients and verify the HIM department receives all charts.
• Copy routine operative notes for specified doctors the day after surgery and put in appropriate area to mail. Ensure operative notes reflect the procedure that was performed.
• Put routine operative notes on appropriate charts.
• Review charts once they have been signed by the surgeon / anesthesiologist ensuring chart is complete.
• Pull charts needing signatures for any doctor performing surgery the next day. Take charts to designated area for completion.
• Verify all pathology reports have been received from Delta Pathology.
• Match old dictated reports with charts when the surgeon has dictated after the date of surgery.
• Respond to release of information requests while maintaining compliance with CLSH policies, departmental procedures, and applicable state and federal laws.
• Perform other duties as assigned by the HIM Director to maintain the department.
• Comply with facility Standards of Behavior and complete all required education assignments within the designated timeline.
• Participates in cross-training as needed.
• Notifies Director immediately of any potential problems involving job functions, equipment failures or other issues that could impact productivity.

Physical Demands

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.
• The employee must be able to lift and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.
• The employee must be able to stand and/or walk at least two hours per day.

Work Environment

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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