CLASS TITLE: MEDICAL RECORDS CLERK
GENERAL DEFINITION OF CLASS:
To perform medical records/clerical duties on a hospital ward or medical records office focused on the maintenance of clinical ward charts, and organization of related duties to aid the charge nurse or medical records administrator in efficiently running the ward/office.
Works under the immediate supervision of a ward nurse, medical records, or other superior from whom assignments are received and by whom work is checked upon completion. On the ward, has direct liaison with the Office of Medical Records regarding guideline for filing order, confidentiality of information and Hospital Policies and Procedures.
ILLUSTRATIVE EXAMPLES OF WORK PERFORMED:
(Assignments may include but are not limited to accomplishment of the following essential functions):
To assure that all patients have name bands, bed and door identification.
To check charts, forms and reports for order and completeness; stamp all forms with patient name plate to assure that all charts are up to date; include daily information updates (e.g. record temp, pulse, resp. daily); make entries on ward forms, charts and records, make copies as needed and send materials to medical records.
To prepare various records, reports, schedules as directed when patients are transferred or discharged.
To assist authorized personnel in locating charts, reports and other information.
To use basic office equipment (fax machine, copy machine, etc.) as needed.
To send charts and mail to proper departments.
Copy from chart specific items (requested by physician, social workers, nurse) on Release of Medical Record Information Forms, to be mailed or faxed, to clinics or agencies involved in continued treatment, or future placement of a patient being prepared for discharge.
Copy from chart specific items (requested by medical records) for requests for release of medical information.
To make internal and external appointments for patients with doctors, hospitals, clinics, x-ray, etc; arrange transportation; send appointment slips or mail to proper locations.
To notify information desk and relevant departments when patients are transferred, admitted or discharged.
To notify dietary department of new diet orders or changes.
To serve as phone and in person receptionist to patients, physicians, personnel, visitors and clergy.
To give messages to department supervisors, personnel and patients as necessary.
To keep up-to-date listing of emergency phone numbers.
To pick up and deliver mail daily.
To keep nurses station clean and in order (including files, bulletin board, etc.)
Perform related work as required.
REQUIRED QUALIFICATIONS FOR APPOINTMENT:
KNOWLEDGE, SKILLS AND CAPACITIES:
A working knowledge of medical terms and hospital procedures; the ability to make tabulating and arithmetical computations; the ability to understand and carry out oral and written directions; the ability to maintain files and records and related capacities and abilities.
EDUCATION AND EXPERIENCE:
Such as may have been gained through graduation from a senior high school; and
(prior work should include activities such as):
Such as may have been gained through: employment in a clerical position with responsibility for the organization and maintenance of records.
OR: any other combination of education and experience that shall be substantially equivalent to the above education and experience.
ADA MEDICAL PROVISION:
If a medical certificate of fitness is necessary, it will be required of all applicants to this class. The certificate is to be submitted only after a conditional offer of employment has been made in accordance with the Americans with Disabilities Act.
If an applicant is unable to perform any essential job functions because of his/her disability but can achieve the required results by means of a reasonable accommodation, that applicant shall not be considered unqualified for the position.