Medical Records Tech - 1st Shift

Job purpose

To provide Medical Clerical support for the DNS Medical Nursing 5W at the Walter Reed National Medical Center 8901 Wisconsin Avenue Bethesda MD) Contract for 8koi; a diverse Florida based service and consulting company that has been providing outstanding results for our clients for over 25years now.

Duties and responsibilities

• Transcribe physician orders involving patient activities diets tests and medications.
• Transfer orders on a timely basis to various records in accordance with departmental and directorate policies.
• Complete request forms of individual patient orders for special blood work xrays radiation therapy diets clinic appointments respiratory and ventilator care consults and other requests as may be deemed necessary.
• Answer the telephone record and relay messages and/or redirect calls as necessary.
• Record telephone messages pertaining to such things as detailed laboratory reports xrays and test results recognize and refer urgent ones to the professional staff for immediate action.
• File the results of various tests in patients charts for professional staffs reference keeping record of care current and accurate.
• Enter and/or retrieve data from the Composite Health Care System (CHCS) and the Clinical Information
• System (CIS) as appropriate to the area assigned.
• Maintain all patient records in correct sequential and chronological order with each page properly identified.
• On discharge or transfer of patients verify and assure that records of patient treatment are complete.
• Provide clerical tasks inherent in the admission and discharge of patients.
• Notify appropriate doctor of patients admission.
• Explain discharge procedure and direct the patient to appropriate checkout areas; e.g. collection agent pharmacy etc.
• Maintain logs and records such as repair requests long distance calls etc.
• Prepare and maintain statistical information for cost accounting purposes as needed.
• Transport specimens to various laboratories or clinical areas.
• Pick up blue cards in the Patient Admin Department and other routine places.
• Make up admission packets.
• Copy forms file and sort mail.
• Provide clerical support to the Hematology/Oncology Department which has approximately 42 admissions and 24 discharges a week.
• Complete an average of 60 request forms a week.
• Maintain an average of 25 patient records.
• Maintain approximately 3 logs and records for the department.
• Transport an average of 42 specimens a week.
• Pick up an average of 42 blue cards a week.
• Prepare an average of 42 admissions packets a week

Qualifications

High School diploma or equivalent and 23 years of clerical experience (i.e. MSA/Medical Clerk/Administrative

Support/General Clerk.

• Must be able to obtain US Government Security Clearance
• Thorough knowledge of unit procedures for assembling patient charts recording physicians orders integrating xray and test reports graphing and charting medical data and scheduling patient appointments to independently perform the clerical work of the unit relevant to patient care and treatment.
• Knowledge of the various facility services the medical terminology and procedures common to each service in order to record and report test and xray results accurately respond to patient inquiries and give necessary directional information to patients.
• Knowledge of the internal organization of patient records and the relationship of their parts in order to review records for completeness accuracy and consistency with facility requirements.
• Knowledge of basic computer skills in order to enter and extract patient information. Ability to use the keyboard and special function keys of a specialized computer system (e.g. CHCS CIS) to enter and retrieve data produce routine reports. Data entry must be made with some speed and accuracy 20 to 25 words per minute sufficient). However the skill of qualified typist is not required.
• Knowledge of communication skills and proficiency in the English language in order to allow for tactful and diplomatic relations with all levels of staff patients and their families.
• Must have current Basic Life Support Automated External Defibrillator (BLS/AED) resuscitative medicine training certificate. Resuscitative medicine training provided by the Joint Medical Training Facility (MTF) or Center.

Working conditions

Working conditions are within a normal office environment.