Medical Records Secretary
Posted on Mar 12, 2019 by Heinzerling Foundation
The Medical Records Secretary is responsible for organizing and coordinating the operation of the residents' medical records, assisting other departments in the use and completion of medical records and following up on signatures and missing information, inventory ordering and stocking of medical supplies. This person also acts as a secretary to the nursing department and the physician, maintaining confidentiality in accordance with state and federal regulations.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Responsible for nursing supply inventory including medical supplies, office supplies and over the counter supplies and equipment
Establishes working relationships with suppliers and vendors
Facilitates communication and negotiates prices when necessary for department medical supplies
Ensures all filing is completed daily
Responsible for all updating and/or typing required by the physician and nursing department (ie reports, lists, forms, memos, letters, minutes, physicals, etc.)
Responsible for all filing of medical record reports and evaluations
Submits a monthly list of all residents' evaluations needed (ie physical, psychological, speech, immunizations, therapy assessment, nutritional assessment, social history, etc.) to other departments.
Responsible for checking nursing documentation including nurses notes, seizure records, kardexes and monthly summaries
Ensures orientation packets are prepared for orientation
Responsible for minutes of shift coordinators' meetings, day shift nurses meetings, quarterly infection control meetings and all resident meetings called by the physician or nursing department
Responsible for the confidentiality, receipt and release of medical information and records in accordance with state and federal regulations
Responsible for all paperwork, including master resident indexes, associated with all residents, admissions, transfers and discharges
Maintains chart sign out and follows up on chart locations
Creates charts for newly admitted residents
Tracks all residents' medical assessments
Prepares all residents' discharge summaries for on-site and off-site storage
Updates all lists within nursing and medical records departments as needed
Performs clerical duties and responsibilities as assigned by the Director of Nursing
Participates in initial, required and ongoing staff development trainings and in-services
EDUCATION and/or EXPERIENCE
High school graduate or equivalent (Medical experience or education in a related health field preferred).
ADDITIONAL SKILLS AND ABILITIES
Ability to use a computer proficiently.
Ability to work competently with Microsoft Office Products, especially Word and Excel.