The Medical Records Coordinator is responsible for organizing and maintaining accurate and secure medical records for the skilled nursing facility. Duties include reviewing resident electronic health record (EHR) documentation and provider visit documentation; monitoring of notes and reporting findings to the clinical and interdisciplinary team (IDT); EHR filing/scanning; and setting up and closing resident charts. The Coordinator works collaboratively with the systems HIM department staff to prepare records for offsite storage retention record destruction and ensure the safeguard and protection of patient health information. Additionally this role supports the release of medical records for continuity of care and other authorized purposes ensuring compliance with organizational policies and regulatory standards.
Accountabilities
1. Manages facility census and works collaboratively with facility business office team.
2. Completes reviews of resident EHR documentation and reports findings to the leadership team.
3. Monitors EHR data and provides results to the clinical team and IDT highlighting omissions or other documentation needs that require followup action.
4. Monitors and ensures provider visits have corresponding visit documentation in the EHR (per regulatory requirements).
5. Ensures offsite appointments are captured in the EHR with visit summary and/or new orders.
6. Sets up new admission charts and closes resident charts upon discharge.
7. Completes EHR scanning filing and thinning of residents soft charts. Retrieves and delivers health records as needed.
8. Processes internal and external requests for release of records. Follows CHSs Release of Information and faxing policy and procedures safeguarding the patients confidentiality.
9. Protects and safeguards health records ensuring confidentiality and compliance with HIPAA and other regulatory standards.
10. Answers and processes incoming telephone calls faxes and email communications from internal and external customers requesting information.
11. Reviews and prepares medical records and miscellaneous resident information for offsite storage retention or permanent destruction in accordance with policy and procedure and in collaboration with the CHS HIM department.
12. Serves as a liaison between the skilled nursing facility and the CHS HIM department for systemlevel initiatives and updates.
13. Maintains effective communication and collaborates with facility staff and other departments to resolve discrepancies or issues.
14. Provides training or support to staff on documentation and EHR processes as needed.
15. Perform other jobrelated duties as assigned.