POSITION:
The Medical Records Assistant is to perform accurate and timely transcription of physician, nursing and other provider orders.
computer order entry; maintaining resident medical charts and communicating pertinent information to staff members.
REPORTING:
This position is responsible to the Medical Records Director.
FLSA STATUS: Non-Exempt
ESSENTIAL JOB FUNCTIONS:
• Transcribe, accurately, physician and nursing orders on appropriate documents in a timely manner
• Keys information into computer systems, including EMR
• Assure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as required
• Record accurate, legible information about resident care and condition in appropriate sections of resident’s records
• Follow facility policies and procedures including those related to infection control
• Capable to perform new duties as assigned and trained
• Maintain resident medical charts, station documents and supplies
• Input physician and nursing orders to computer
• Establish and maintain effective communication both written and verbal
• Able to interact effectively with individuals who are cognitively and/or physically impaired
• Organize nursing stations and maintain a tidy work environment
• Perform chart audits as assigned
• Demonstrate ability to maintain confidentiality of resident and facility information
• Prioritize workload and complete projects accurately and in a timely manner
• Assist with preparation for state inspections as directed. Attend survey training and interact with state surveyors as
directed by immediate supervisor
• Demonstrate interpersonal skills that contribute to a positive work environment
• Demonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactions
• Provide excellent service to staff, visitors, and residents
• Answer telephone professionally and in accordance with facility policy
• Demonstrate competence in use of proper body mechanics for both upper and lower body
• Monitor physical environment for safety or fire hazards and corrects or reports potential problems immediately to
Charge Nurse. Promptly reports housekeeping and maintenance problems to Charge Nurse
• Report injury to resident or self to Charge Nurse immediately
• Participate in fire and disaster drills. In the event of any emergency, carries out assigned duties to assure resident
safety
• Knowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond to
written or oral instruction in case of emergency
• Adhere to policies and procedures
JOB FUNCTIONS:
• Demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions
• Appreciates the importance of maintaining confidentiality of resident and facility information
• Demonstrate honesty and integrity at all times in the care and use of resident and facility property
• Must be able to key information into computer systems
• Good communication skills both verbal and written
• Proficient in English
• Able to understand and follow written and verbal directions
• Working knowledge of basic computer programs: Word and Excel
• Basic and advanced typing
• Basic and advanced filing
• Working knowledge of medical terminology
• Open, flexibility to changing needs of the Medical Records Department
• Other duties as assigned
PHYSICAL CAPACITIES: (With or Without the Aid of Mechanical Devices)
• Must be able to move intermittently throughout the workday.
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the
requirements of this position can be fully met.
• Must meet the general health requirements set forth by the policies of this facility which includes an annual TB
screening and physical examination.
• Must be able to sit for extended periods of time.
• Must be able to lift and carry up to 25 pounds.
• Must be able to cope with the mental and emotional stress of the position.
ENVIRONMENTAL CONDITIONS:
Inside work, normal temperatures, some noise, occasional fumes/odors, chemical exposure and potential exposure to blood
borne pathogens, traveling to on-site locations.
This job cannot be performed without exposure to the stresses associated with an intimate, 24 hour skilled care environment
that delivers care and services primarily to disabled and cognitively impaired residents in an aging population. Examples of
these stresses include, but are not limited to: emergency health or safety response, weekend and holiday duty, unusual or
impaired behavior by residents, family reactions to having a loved one in a nursing home, death and dying, oversight of state
surveyors, ombudsmen and federal officials, presence of consultants and attorneys, and variable involvement of medical staff.
