Assumes authority, responsibility, and accountability for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long term care facilities. Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible, and systematically organized. Collaborates with the Nursing Home Administrator to allocate department resources efficiently and economically to achieve department objectives.
Ensures that all clinical records contain sufficient information to identify the resident; records of assessments; the plan of care and services provided; results of State preadmission; and progress notes.
Initiates and participates in the development of facility policies and procedures to ensure that medical records are complete, accurately documented, accessible, and systematically organized.
Develops and implements record storage and retrieval systems compliant with retention laws, maintaining record accessibility.
Inspects closed records for completeness and systematically organizes them for long-term storage. Reports delays to Nursing Home Administrator.
Develops and maintains safeguards against unauthorized access and use of computerized medical records.
Evaluates medical record forms and formats; recommends changes to improve quality of records and record-keeping practices.
Evaluates compliance with medical records documentation policies via record reviews; reports findings to Nursing Home Administrator and Director of Nursing Services.
Develops and conducts educational programs for facility staff on documentation policies and practices, ensuring understanding of confidentiality and compliant information release.
Maintains and distributes lists of facility-approved abbreviations and definitions.
Provides access to all resident records within 24 hours of request; provides photocopies within two working days.
Develops safeguards against loss, destruction, unauthorized access/use of clinical records, maintaining confidentiality and securing authorized consent for information release.
Advises Administration, physicians, and staff on requirements for control, use, and release of clinical information; advises on confidentiality safeguards for staff medical records.
Conducts periodic quality control assessments of staff compliance with medical records policies; analyzes findings and implements improvements.
Collects and displays clinical data requested by Administration, committees, regulatory agencies, or accrediting bodies.
Participates in department budget development; provides financial information to Nursing Home Administrator.
Maintains communication with Nursing Home Administrator regarding medical record and budget issues; recommends staffing numbers and types to meet facility needs compliantly.
Actively participates in long-term care surveys, instructing staff, maintaining presence during surveys, and directing timely collection of required information.
Takes corrective action during surveys as needed; collaborates on survey report responses.
Maintains current skills and knowledge through continuing education; applies information to responsibilities.
Performs other duties as assigned by supervisor.
High school diploma or equivalent required.
Minimum one year experience as a medical records practitioner in a long-term care facility.
Preferred current certification as an Accredited Records Technician.
Certification as a Registered Records Administrator preferred.
Location
Georgia, US
Employment Type
Full-time
Experience Level
Manager
Remote work allowed
No
Posted
3 months ago