Job Summary:
Assembles and maintains complete medical records according to established procedures. Reviews patient records on an on-going basis and ensures that initial assessment documentation, follow up clinical notes, missed visit orders, care coordination documentation, transfers, resumptions of care, re-certifications, and/or dischargeOASIS documentation are turned into the agency by the clinical staff and incorporated into the medical record in accordance with Lorian Home Systems, Inc. of Las Vegas (LORIAN)’s policy. Assists Clinical Supervisors in the coordination of admitting, transferring, discharging, and the recertification ofpatients.Files and retrieves patient records and prepares new files as needed.
Qualifications
- High School Diploma or Equivalent and some college general education course work
- Good communication skills, written and oral, and good phone etiquette.
- Good computer skills: Knowledge of word and Excel required.
- Ability to develop and maintain filing systems.
- Ability to maintain quality, safety, and/or infection control standards.
- Ability to complete routine paperwork
- Ability to maintain confidentiality of records and information.
- Ability to be flexible, to follow verbal and written instruction and to work in a team oriented
Responsibilities
- Sorts and files loose paperwork in patient charts; maintains medical records in proper order and in accordance with LORIAN’S policy.
- Enters data into computer system from written assessments provided by professional clinical staff.
- Creates patient charts for new patients using unique identification numbers according to established protocol.
- Responsible for ensuring that initial assessment, transfer, resumption of care, discharge and re-certification of patient documentation is turned into LORIAN in a timely fashion.
- On a daily basis, reviews patient pending and re-certification lists to ensure that related documentation is being turned into LORIAN by clinicians according to LORIAN’S timeliness and completeness policy and contacts non-compliant clinicians.
- Responsible for ensuring that visit notes are being turned into LORIAN in a timely manner.
- On an on-going basis, reviews active patient census report and individual patient charts to ensure that visit notes are being turned into LORIAN by clinicians in accordance with prescribed planned visit frequency and LORIAN timeliness guidelines and contacts non-compliant clinicians.
- Responsible for ensuring that missed visit doctors orders are being turned into LORIAN in a timely and accurate manner.
- On an on-going basis reviews active patient census report and individual patient charts and identifies patients with missed planned visits and ensures that corresponding missed visit doctor orders have been created by the clinician and incorporated into chart. If required orders are not present in chart, contacts non-compliant clinician and require compliance.
- On an on-going basis reviews active patient census report and ensures that all transfers to hospital, resumption of care, re-certifications, and discharges, including interdisciplinary discharges, of patients have been properly identified and documented.
- Informs pertinent clinicians of any patients coming up for re-certification or discharge.
- Responsible for ensuring that care coordination forms and other pertinent documentation have been included in patients’ charts
- May perform other routine clerical tasks.
- Performs such other duties as assigned.
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