Medical Records Supervisor supervises routine medical record-keeping operations and healthcare information management to ensure secure, accurate, and reliable patient information management that complies with data and privacy regulations. Follows established policies and procedures to ensure effective and compliant record management, makes suggestions for process improvements. Being a Medical Records Supervisor implements digital technologies and tools to gain efficiencies, facilitate record retrieval, and ensure secure storage. Provides training for medical records staff and information resources to end-users. Additionally, Medical Records Supervisor coordinates with clinical and technical professionals to maintain robust records management systems and manage data for analysis and reporting. May require an associate degree. Typically requires Registered Health Information Technician (RHIT). Typically reports to a manager. The Medical Records Supervisor supervises a small group of para-professional staff in an organization characterized by highly transactional or repetitive processes. Contributes to the development of processes and procedures. To be a Medical Records Supervisor typically requires 3 years experience in the related area as an individual contributor. Thorough knowledge of functional area under supervision. (Copyright 2024 Salary.com)
Wilshire Lakewood Care Center Rehab & Healthcare strives for excellence!
Medical Records Reports To: Director of Nursing
Supervisers: Position requires no supervision of other staff members.
Medical Records Requirements:
Medical Records Duties:
· Maintain nursing/medical records mail log.
· Maintain record of admits and discharges
· Prepare new charts for incoming residents
· Place ICD-10 codes and diagnoses on facesheet and cumulative diagnoses sheet
· Close out charts for discharged residents
· Maintain an organized filing system for resident records
· Ensure that doctors have signed all necessary forms in chart including P.O. forms –this will require both mailing of the documents and communication with the doctors periodically
· Ensure that doctors perform annual physicals for each resident
· Audit each chart within 2 weeks of a new admit for necessary initial assessments (social services, dietary, activities, nursing)
· Audit each chart periodically for necessary documents including nurse’s notes, monthly summaries, weights and vital signs, doctor progress notes and physicals
· Thin charts every three months and/or at discharge
· File medical records in resident charts
o Telephone Orders
o MDS Records/Careplans
· Maintain stock of nursing forms at nurse’s station for use by staff.
· Assist in keeping nurses station clean and organized.
· Assist in responding to phone calls and family/resident concerns.
· Maintain nurses station fax machine including the replacement of ink cartridges and adding paper.
· Participate in quality assurance functions including but not limited to:
o Acting as secretary to the quality assurance committee including but not limited to keeping minutes, scheduling meetings, and sending meeting notices.
· All other duties as assigned by supervisor.