Job Summary

Responsible for retrieving reports from transcription computer. Edits, copies and charts dictated reports in the appropriate patient medical record. Retrieves and processes discharges and prepares medical records for assembler. Assists physicians with record requests. The Health Information Management Clerk is responsible for securing and maintaining the patient’s health record upon discharge from the hospital. This position verifies and ensures receipt of all patient records, and assembles the documentation into the legal medical record. All loose reports the Health Information Management department receives, including transcribed reports, are patient identified and filed into the legal medical record, as appropriate. Medical records are pulled for authorized requests, and filed in terminal-digit order, while accurately maintaining the chart tracking system and ensuring ease of retrieval. Customer Service is integral to the position as the Clerk is also responsible for answering telephone calls and assisting visitors (including but not limited to physicians, patients and their family members), while maintaining confidentiality.

Demonstrates Competency in the Following Areas

• Collects and records the information about the parents of newborns; obtains signatures in a timely manner as needed on the birth certificate. (Deliveries in ED only)
• Assists transcription service with obtaining correct names and medical records as needed.
• Prepares folders for new admissions, obtaining old records as needed.
• Updates medical record locator report at end of each shift.
• Assists in retrieving medical records for physician completion.
• Answers telephone and takes accurate messages.
• Performs performance improvement functions through data collection and documentation review.
• Is familiar with pediatric and SNF medical record requirements.
• Maintains a good working relationship with physicians and other departments.
• Supports and maintains a culture of safety and quality.
• Willingly accepts additional assignments.
• Demonstrates knowledge of basic medical terminology related to the performance of job duties.
• Demonstrates working knowledge of terminal digit filing systems and concepts of unit records.
• Demonstrates ability to accurately and efficiently utilize the hospital information system and MPI print-out to research a medical record number.
• Demonstrates complete knowledge of the principles of medical documentation.
• Demonstrates ability to analyze Emergency Room records: knowledge of documentation requirements & accurately assigns deficiencies to responsible physicians.
• Serves as a model to fellow hospital employees in the area of confidentiality.
• Demonstrates working knowledge of information systems related to job duties.
• Possesses awareness of hospital processes, location of departments, convenience areas, and other related patient/visitor services.
• Regularly attends department meetings and in-service training programs to remain aware of pertinent developments and/or changes in related policies, procedures, and systems.
• Regularly consults with supervisor on areas of further instruction that would be beneficial, and discusses any pertinent issues.
• Maintain confidentially, protecting patient information at all times: minimum information necessary to those with the right and need to know.
• Employee verifies receipt of all records and promptly locates records not received.
• Accurate preparation of medical record folders according to department procedures.
• Maintains the unit record system by combining all patient records into one color-coded folder.
• Assist in resolving medical record discrepancies when identified, and communicate corrections in medical record numbers to appropriate personnel.
• Consistently files medical records as assigned, and in strict terminal-digit order.
• Helps with the purging of medical records, and retrieves or orders records from storage as needed.
• Retrieve patient records for readmission, emergency room or outpatient visits, committee meetings, and other activities sanctioned by the hospital within the timeframes required.
• Accurately maintains and consistently utilizes the chart location system.
• Receives, verifies, and distributes all transcribed reports appropriately.
• Audit & correct demographic errors (patient name, DOB, MRN, and account #) identified on transcribed reports. Notify the transcription service of the need for correction to the appropriate work type.
• Determine patient identification of loose reports, and accurately file in the appropriate location (according to established chart order) within the correct visit of the patient’s medical record.
• In an accurate and timely manner assemble the discharged records into the legal medical record per the established chart order, and verify each document belongs to that record.
• Accurately verify the completeness of the emergency room medical staff documentation and assign any deficiencies to the appropriate medical staff member for completion
• Proactive in answering telephone calls and offering assistance to all customers by telephone or in person.
• Effective communication: writes and speaks clearly and concisely, affecting positive and efficient assistance to all requestors.
• Perform required tasks and other duties as assigned, while maintaining a positive attitude.
• Completes job duties in accordance with production requirements and quality standards.
• Promptly report equipment malfunctions to the appropriate personnel to order service as needed.
• Inventory supplies needed to perform job duties and place orders on a regular basis to ensure an adequate supply at all times.
• Independently recognizes and performs duties that need to be done without being directly assigned. Establishes priorities; organizes work and time to meet them.
• Recognizes and responds to priorities, accepts changes and new ideas. Has insight into problems and the ability to develop workable alternatives.
• Accepts constructive criticism in a positive manner.
• Adheres to attendance and punctuality requirements per hospital policy. Provides proper notification for absences and tardiness. Takes corrective action to prevent recurring absences or tardiness.
• Uses time effectively and constructively. Does not abuse supplies, equipment, and service.
• Observes all hospital and departmental policies governing conduct while at work (e.g., telephone and computer use, electronic messaging, smoking regulations, parking, breaks, and other related policies).
• Patient-Centered:Respectful of and response to patients preferences, values, and needs
• Accountability & Customer Focused: Participates actively and positively affects the outcomes of customer service activities
• Teamwork & Communication: Is a team player and communicates effectively at all levels
• Privacy & Safety: Follow and abide by all privacy (HIPAA) regulations regarding patient information
• Attitude & Respect: Being sensitive to customer/co-worker emotions, thoughts, and feelings by being culturally aware of their preferences and cultural norms in a courteous and professional manner
• Understands and abides by all departmental policies and procedures and is knowledgeable and complies with federal, state, and local laws that govern business practices as well as all accreditation standards that apply to the position.
• Conducts business in an ethical and trustworthy manner at all times.
• Attends scheduled in-service and mandatory in-service. Communicates ideas to the supervisor for a safer layout of equipment, tools, and/or processes.
• Follows standard precautions and transmission-based precautions.
• Adheres to procedures for proper disposal of medical sharps, pharmaceutical, and medical waste per hospital policy
• Is knowledgeable in the hospital safety program and takes necessary steps to maintain a safe environment. Adheres to safe work practices in order to prevent injuries and illnesses.
• Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes
• Active participant in Continuous Quality Improvement program by assisting in finding new and better ways of performing duties and responsibilitie
• Understands performance improvement concepts and demonstrates understanding by:a) Defining performance improvement, and verbalizing at least one major goal of the performance improvement program within the hospital setting.b) Able to verbalize at least one departmental or hospital-wide improvement initiative that has occurred within the last 12 months.

Regulatory Requirements

• High School graduate or equivalent.
• 2 or more years of previous similar hospital experience.
• Knowledge of accrediting organizations and state regulations.
• Ability to work with patients/families and physicians in a collaborative manner.
• Experience with accurate alphabetic and numeric filing; preferred. One year of hospital experience; preferred.
• Knowledge of terminal digit filing and medical terminology; preferred.
• Computer data entry with 10-key, with an accurate typing speed of 35 wpm; preferred.
• Completion of a medical terminology course; is preferred.
• Background in business and office training; preferred.