Job Description

University of Utah Job Description

Job Summary

Compiles, assembles and organizes patient medical records in department files and in the department’s computer system and makes record information available to staff. Ensures compliance with medical recordkeeping policies and researches and resolved medical record deficiencies.

Qualifications

Three years of medical record compilation experience in a healthcare environment or equivalency (one year of education can be substituted for two years of related work experience); demonstrated knowledge of chart flow and chart construction, medical terminology and coding; completion of college courses in anatomy and physiology or completion of hospital provided courses; and demonstrated human relation and effective communication skills required.

This position is patient-sensitive and must fulfill all associated vaccination requirements, or be approved for an exemption, prior to the first day of work. We protect our patients, coworkers and community by requiring all patient-sensitive employees to be immunized according to CDC standards and hospital policy. Limited exemptions may be made for documented medical contraindications or religious beliefs that object to vaccinations.

Applicants must demonstrate the potential ability to perform the essential functions of the job as outlined in the position description.

Disclaimer

This job description has been designed to indicate the general nature and level of work performed by employees within this classification.  It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to the job.

Essential Functions

1. Sorts, assembles, organizes and files all accumulated notes and reports into patient medical records; accounts for and files all transcribed reports.
2. Reviews records of admitted patients and ensures completeness and compliance with hospital, state, and Joint Commission standards.
3. Documents Resident chart/record completion performance; prepares weekly reports identifying deficiencies made by Residents; sends reports to the appropriate attending physician.
4. Analyzes charts to ensure that medical record completion and compliance guidelines are met; works with physicians to correct any deficiencies in the medical records.
5. Interviews obstetrical patients and prepares computer generated birth certificates; transmits birth certificates to the State Health Department.
6. Acts as liaison with Transcription vendor; tracks timely dictation of charts; requests dictated operative and discharge summaries from surgeons and physicians when necessary.
7. Uses the department computer system to update records, audit information, generate reports, and prepare graph information.
8. Organizes discharge summaries and operation reports, enters reports into the patient’s medical record, and forwards records to the Health Information Coders.
9. Prepares doctor’s signature recertification reports for patients who have been hospitalized for more than 60 days.
10. Performs other duties as assigned.

Problem Solving

If assigned leadworker status, the incumbent is authorized to schedule, direct, and oversee the work of Health Information Specialists and other department personnel. The incumbent is authorized to determine if patient records meet regulatory agency standards and take action required to ensure that they do so when necessary. The incumbent is authorized to recommend suspension and/or fine physicians that are not in compliance with chart completion policies as per hospital bylaws. The incumbent provides training on medical record policies to hospital physicians and evaluates recordkeeping performance.

Challenges encountered by the incumbent include identifying computer problems and working with computer technicians to make necessary repairs; locating lost or missing records; accurately updating and resolving record deficiencies; and making information available to physicians in a timely manner.

Comments

Work Environment and Level of Frequency typically required

Nearly Continuously: Office environment.

Physical Requirements and Level of Frequency that may be required

Nearly Continuously: Sitting, hearing, listening, talking.

Often: Repetitive hand motion (such as typing), walking. 

Seldom: Bending, reaching overhead.

The staff member must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit.  The individual must demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.