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Maintains record of patient care by compiling, reviewing, and filing documentation of patient's condition, treatment, and health outcome.
Job Responsibilities:
Maintains medical records operations by following policies and procedures; reporting needed changes.
Initiates medical record by searching master patient index; identifying existing patient records or need to assign a new number; interacting with registration areas and physicians' offices for information verification; processing or creating the record folder.
Ensures medical record availability by routing records to admissions and emergency departments, physicians, and other authorized hospital staff; maintaining chart location systems.
Completes medical record by reviewing information; notifying health care providers of record deficiencies; tracking outstanding records; notifying medical director of physicians in jeopardy of losing admitting privileges.
Maintains historical reference by abstracting and coding clinical data, such as diseases, operations, procedures, and therapies, using standard classification systems; filing documents.
Provides medical record information by answering questions and requests of patients, hospital staff, law firms, insurance companies, and government agencies.
Maintains patient confidence and protects hospital operations by keeping information confidential; following release-of-information protocols.
Maintains the stability and reputation of the hospital by complying with legal requirements.
Keeps equipment operational by following manufacturer's instructions and established procedures.
Conserves resources by using equipment and supplies as needed to accomplish job results.
Contributes to team effort by accomplishing related results as needed.
Candidate Requirements:
Time Management
Attention to Detail
Quality Focus & Productivity
Documentation Skills - Written Communication
Data Entry Management
Equipment Maintenance
Supply Management Ability to plan & organize ones work schedule effectively.
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