health info manament tech ii - Chicago, United States - Mount Sinai Hospital

Description

GENERAL SUMMARY

Responsible for performing various technical functions including medical record review, analysis, transcription processing, birth certificate completion and record completion.

ESSENTIAL FUNCTIONS AND DUTIES: Performs medical record review utilizing JCAHO tools. Review a minimum of 50 inpatient/ outpatient charts per month. Analyzes data collected and prepares monthly and quarterly reports. Collects data for identified PI indicators, prepares and generates reports on PI indicators. Review daily report logs for misidentified patients and dictating physicians. Makes appropriate corrections the same day. Collects and reports data on all quality issues. Educates physicians on how to dictate. Monitors do the TAT day daily. If the turnaround time is greater than standard, report immediately to the supervisor/ team leader. Abstracts clinical data from both the mother's and infant's records to complete the newborn birth certificate. Prepares an accurate, typed birth certificate for every live birth within 72 hours of birth. Conducting interviews with every mother to ensure the accuracy and completeness of information obtained in preparation of a birth Certificate ensures that single mothers are adequately informed of the affidavit procedures for a father's name to be placed on Birth Certificates. Obtains signatures of both the mother and father on all completed Birth Certificates. Complete paternity forms. Pulls records for residents and attend immediately if a physician is present. If the request is by phone, records must be pulled within the time frame requested by the physician. Reanalyzes all records completed by physicians by the end of the work day. Assures that all residents have been recorded utilizing the transcription software. Places reanalyzed records in sorter for refiling. Refills any charts not dictated within five days of pulling. Keeps record completion area neat and orderly at all times and ensures that all equipment is working properly. Review each medical record upon discharge.

MINIMUM EDUCATION: High school diploma or G.E.D. equivalent.

MINIMUM WORK EXPERIENCE: Preferably one year of medical records experience and knowledge of medical terminology Basic computer skills