Under the direct supervision and guidance of the Operations Manager, the Medical Record Document Imaging Technicians perform a variety of duties related to processing discharged records, and chart completion review. This process is performed to maintain complete and accessible patient medical record documentation required for patient care, hospital licensing, federal and state compliance regulations.
Major Position Responsibilities:
- Retrieves the discharged patient’s medical records for all hospital services whose records are maintained by the Department.
- Label Fetal Monitor Strips and file in alphabetical order in storage cartons.
- Preps the discharged patient record by removing staples, paperclips and sticky notes. Verifies each page is labeled with the correct patient’s information. Arranges the orders and progress notes in date order from admit to discharge. Groups like bar-codes together (i.e. all consents, transfusion documents, etc.).
- Scans the medical record into the Kofax Document Imaging application. Rotates pages and deletes blanks. Creates “books” by date for orders and progress notes as necessary.
- Quality checks each record to confirm all pages have been scanned. Verifies “books” were created accurately and pages are in the correct order. Reviews each scanned page for acceptable image quality. Verifies the correct patient information on each page. Rearranges, rescans pages as necessary. Places records in cartons for storage and moves boxes to holding area within permanent file.
- Validates all documents have been indexed properly. Assigns dates to orders and progress notes as necessary. Verifies final accuracy before releasing record for viewing.
- Concurrently scans orders and progress notes for patients currently in-house Monday through Friday.
- Reviews and verifies physician chart deficiencies for a complete medico legal record document. Assigns deficiencies to the electronic record for completion of unsigned documents and dictated reports.
- Assists in various Medical Record Technician Support functions on assigned coverage days and for department meeting coverage.
- Efficiently utilizes the Medical Center’s medical record patient index, chart deficiency, and other computerized department products that are used in the performance of all assigned duties.
- Performs other related duties or projects as requested by the management of the Medical Records Department.
Safety and Infection Control Responsibilities:
Responsible to maintain a safe and clean work environment, including unit based specific safety and infection control requirements.
- Two years experience in a medical office or completion of Medical Assistant/Administrative coursework – Required.
- Detail oriented individual who can handle multiple tasks within outlined deadlines.
- Excellent organization and clerical skills.
- Computer literacy / Typing proficiency – 35 wpm required.
- Knowledge of medical terminology and previous medical record experience preferred.
- High School diploma or GED, required (effective 8-1-11)
- Medical Assistant/Medical Administrator Assistant preferred