Medical Records

Medical Records Responsibilities Protect the security of medical records to ensure that confidentiality is maintained. Process resident admission and discharge documents. Review records for completeness, accuracy and compliance with regulations. Maintains resident’s medical files and retrieves files for scheduled appointments; files all patient data upon receipt of information; initiates records for new residents; prepares file labels; audits filing sequence. Release information to persons and agencies according to regulations. Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information. Responds to requests for medical records; processes letters and reports; answers and directs telephone calls. Distributes lab reports to nurses and medical staff, and materials to other departments; requests information from various departments; responds to correspondence requests. Required Skills Be of legal working age Be able to read and follow written directions Be able to communicate with residents and co-workers in English Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public. Work overtime is necessary Must possess a general knowledge and understanding of state and federal laws as they pertain to long term care Must have the current federally required vaccines or proof of a valid exemption.