Unit Clerk at Arbors at Elkins Crest Extendicare Health Services, Inc. - Elkins Park, PA Extendicare Health Services, Inc. 140 reviews Read what people are saying about working here. Responsible for medical records through preparation, compilation, analysis, maintenance and filing. Maintains a well-organized system of closed and open medical records so that records are available to interdisciplinary personnel as need for resident care and other authorized activities. Assists facility in upholding the confidentiality of medical records and protecting the resident’s privacy rights. Assigns ICD-9-CM diagnostic codes to conditions upon admission, during the stay and at discharge. Orders forms and equipment as needed per facility policy and procedure. Assists nursing in general secretarial and clerical duties. May notify the laboratory and x-ray that tests are to be done. May make clinic or physician appointment for residents. REPORTING RELATIONSHIPS: No direct reports. ESSENTIAL FUNCTIONS: Admission Records Assemble the chart following the open chart order and complete the headings on all forms. Assure chart tabs are readable. Label chart back and chart holder. Color code according to facility system. Set up file folders with resident’s name and number for forms thinned from the record. Complete other admission procedures as instructed such as tickler file cards, resident index card, department notification, and resident admission register. Contact transferring facility to obtain missing date if necessary. Maintenance of Records Maintain charts at nursing stations in a clean and orderly fashion. Maintain resident record in proper order per open chart format. Provide diagnostic and treatment information to third party payers to support reimbursement claims. Assign diagnostic codes to newly identified resident conditions and diagnoses for reimbursement, MDS completion and internal purposes. Evaluate requests for information from medical records to assure releases are made only in compliance with state and federal laws. Thin records according to procedure. Assure current and admission information remains on the chart. File thinned paper according to chart order in the proper file folder. Check all sheets thinned from the open chart for completeness. Retain and destroy records per retention policies and procedures in accordance with state and federal laws. Retrieve records for use by administrative or interdisciplinary personnel for resident care, quality improvement, incident tracking and investigation and other authorized purposes. Head all chart forms with resident name ID number, physician and room number. Insert in chart as needed. Enter telephone orders, laboratory and x-ray reports on a daily basis per facility system. Process and monitor completion of physician telephone orders to authorize administration of medication, treatments, therapies, and other services. Enter vital signs and weights in resident’s charts as requested. Comply with federal and state laws concerning release of information from medical records. Copy information as requested form authorized persons. File authorization for release of information in medical record. Maintain confidentiality of all information in the medical record. Maintain forms at the nursing station as needed. Auditing of Open Charts Audit charts on an ongoing basis for MDS completion, summaries, weights, vital signs, physician order signed, etc., using facility audit form. Communicate findings to Unit Nurse Manager, Director of Nursing Services, and interdisciplinary department managers for follow-up. Evaluate medical records on an on-going basis for missing documents, charting or signatures. Notify appropriate interdisciplinary department for follow-up. Check monthly flow sheets for completion, i.e., medication administration records, treatment sheets, vital sign flow sheets, resident care records, restraint and position change sheets, etc. Obtain completion and place in chart. Check charts due for physician visits, annual physicals. Notify Nursing and follow-up as directed. Discharge Records Assemble discharge charts according to closed chart order. Assure all forms are completed with dates, proper signatures, etc. Request completion of forms from all departments as needed. Assign diagnostic codes to final diagnoses at discharge. Notify outside care providers of deficient records per facility system (phone, call, mail). File discharge chart Retrieve records when requested by medical staff or other authorized persons. List records that have been pulled with date, reason and person. Check returned record for organization and completeness, and re-file. Collect and prepare statistical data as requested. Develop knowledge of and adhere to the state and federal laws regarding the legal aspects of the medical record. Answer telephones, take and relay information in a courteous manner. Communicate with the director of nursing services on a daily basis and as necessary about progression of work flow. Handle correspondence as requested. Order all charting forms monthly per facility policy and procedure. Attends and participates in in-service training, performance improvement (“PI”) committees and other meetings as scheduled and directed. Treats all residents, visitors, and staff with courtesy. Works overtime, holiday and weekend hours as scheduled. Assists in orientation and training of employees as assigned. Complies with laws and regulations applicable to position and acts in accordance with Extendicare Health Services, Inc.’s Corporate Compliance Program. Follows facility dress and hygiene policies. Safety Knows and follows facility rules. Demonstrates proper use of equipment. Reports equipment needs or repairs. Follows facility smoking policies. Reports and documents any incidents or accidents of residents, staff or visitors to the appropriate facility personnel. Performs duties, which may include transportation of residents, as assigned in Facility Disaster Plan. Uses required protective equipment. Follows infection control standards, policies and procedures. Reports all hazardous conditions/equipment to Supervisor. Resident Rights Knows Resident Rights. Helps the residents/patients exercise and/or protect their rights. Reports resident/patient complaints to management. Maintains confidentiality of resident/patient information. HIPAA Follows and adheres to Extendicare’s policies and procedures implementing HIPAA requirements for the privacy and security of protected health information. Uses and/or discloses only minimum amount of Protected Health Information necessary to complete assigned tasks (applies only if position requires access to PHI under Role Based Access Grid). Reports all suspected violation of company’s HIPAA policies or procedures to Facility Privacy Designee. Other Duties: Performs other duties as directed by facility management. Participates in all-hands dining. Minimum Requirements MINIMUM QUALIFICATIONS: Education: High School diploma or equivalent. Experience: Prior experience working in a long-term care facility and knowledge of medical terminology a plus. Skills, Knowledge and Abilities: Knowledge of medical terminology. Ability to follow directions and work independently with minimal supervision. Ability to relate positively, effectively, and appropriately with residents, families, community members, volunteers and other facility staff. Meets all health requirements imposed by law. Able to read, write, speak and understand English. 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Posted on: Wed, 21 Jan 2015 03:04:48 +0000
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