Job Summary:

Assembles and maintains complete medical records according to established procedures. Files and retrieves patient records; prepares new files; may open and distribute mail.

Qualifications

• High school diploma or GED; no previous work experience required.
• Ability to develop and maintain filing systems.
• Ability to maintain quality, safety, and/or infection control standards.
• Ability to complete routine paperwork.
• Records maintenance skills.
• Knowledge of related accreditation and certification requirements.
• Ability to maintain confidentiality of records and information.
• Skill in the use of operating basic office equipment.
• Ability to follow routine verbal or written instructions.

Responsibilities

• Sorts and files loose paperwork in patient charts; maintain medical records in proper order.
• Enters data into computer systems from written assessments provided by professional clinical staff.
• Creates patient folders for new patients using unique identification numbers according to established protocol.
• Retrieves patient charts and re-files charts in proper sequence; completes out guides for pulled charts.
• Copies physician-dictated reports and complies with requests for copies of patient records from patients and other persons such as physician’s, attorneys, and insurance companies following departmental policies to safeguard patient confidentiality.
• Locates records which have been checked out or are missing, in accordance with departmental policies for safeguarding patient records.
• Follows established departmental policies, procedures, and objectives, continuous quality improvement objectives, and safety, environmental, and/or infection control standards.
• May perform other routine clerical tasks.
• Performs such other duties as assigned.