Medical Records

Job description

Description JOB TITLE: MEDICAL RECORDS: JOB CODE: 29: DEPARTMENT: NURSING: FLSA STATUS: NON-EXEMPT: REPORTS TO: DIRECTOR OF NURSING: JOB SUMMARY: Under the supervision of the professional nurse, performs a variety of clerical duties associated with patient care unit operations. ESSENTIAL FUNCTIONS: - Written and verbal communication with members of the healthcare team, patients, and visitors utilizing equipment such as the telephone and intercom - Maintain confidentiality of patient information - Assemble, complete, and process patient charts as indicated - Keep patient records accurately identified; maintain an accurate clinical record, recording information per facility policy - Transcribe doctors’ orders per facility policy - Perform daily review of charts for incomplete histories and operative summaries; bringing any compliance issues to the attention of the appropriate member of the health care team for correction - Obtain closed records from Medical Records as needed - Initiate required nursing forms for new admissions and at month end - Order unit supplies to maintain inventory stock and supplies; assist with receiving, distributing and sorting supplies brought to the unit -...