Medical Records - Lee's Summit, United States - Wilshire at Lakewood Care Center

Description

Wilshire Lakewood Care Center Rehab & Healthcare strives for excellence

Medical Records Reports To: Director of Nursing

Supervisers: Position requires no supervision of other staff members.

Medical Records Requirements:

• Must have at a minimum a high school diploma or the equivalent.
• Must have at a minimum a limited ability to use computers.
• Must have understanding of chart and filing organizational systems.

Medical Records Duties:

· Maintain nursing/medical records mail log.

· Maintain record of admits and discharges

· Prepare new charts for incoming residents

· Place ICD-10 codes and diagnoses on facesheet and cumulative diagnoses sheet

· Close out charts for discharged residents

· Maintain an organized filing system for resident records

· Ensure that doctors have signed all necessary forms in chart including P.O. forms –this will require both mailing of the documents and communication with the doctors periodically

· Ensure that doctors perform annual physicals for each resident

· Audit each chart within 2 weeks of a new admit for necessary initial assessments (social services, dietary, activities, nursing)

· Audit each chart periodically for necessary documents including nurse's notes, monthly summaries, weights and vital signs, doctor progress notes and physicals

· Thin charts every three months and/or at discharge

· File medical records in resident charts

o Telephone Orders

o MDS Records/Careplans

· Maintain stock of nursing forms at nurse's station for use by staff.

· Assist in keeping nurses station clean and organized.

· Assist in responding to phone calls and family/resident concerns.

· Maintain nurses station fax machine including the replacement of ink cartridges and adding paper.

· Participate in quality assurance functions including but not limited to:

o Acting as secretary to the quality assurance committee including but not limited to keeping minutes, scheduling meetings, and sending meeting notices.

· All other duties as assigned by supervisor.