Location: Mineral Wells, TX 76067

Shift: Day Shift

GENERAL PURPOSES:

To maintain residents’ medical records in accordance with facility policies and regulations.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

MEDICAL RECORDS FUNCTIONS:

Verify appropriate resident information is entered in the census register. Initiate the active medical record and in-house thinned file, prepare labels, etc. Complete or verify admission checklists and admission audits (if applicable).

Conduct concurrent audits/quality monitoring at regular scheduled intervals. Thin in-house records in accordance with the written guidelines and file in discharge chart order. Audit the thinned records for deficiencies using audit forms. Contact physicians or departments when deficiencies are noted. Maintain a monitoring system to assure telephone orders and other information is signed or completed by the physician as needed. File all incoming medical information in the current record. Monitor timeliness of Physician/Nurse Practitioner on a monthly basis.

Initiate Discharge Summary Process. Assemble medical records from the nursing station and the thinned file and establish in discharge order.

Verify the retrieval of all medical information from various locations, i.e. ADLs, MARs, TARs, etc. Audit the discharge record for deficiencies utilizing a discharge audit checklist. Contact physician or departments as needed to complete discharge audit deficiencies. Follow up and monitor the process for completing the discharge audit deficiencies; complete within 20 working days. Maintain discharge record in an “incomplete record" area until complete. File completed discharge record in “discharge record" section of record department.

Retrieve information from files as requested. Transmit documents as requested by fax, email or other means of transmission. Document all items removed from client files, including information about who received the items, the date and time received, and the date and time the items were returned to the file. Observe HIPPA guideline carefully, and maintain current knowledge of best practices with regard to client/patient privacy issues.

OTHER DUTIES:

Other duties as assigned

Requirements:

• Must have training and certification or experience as required by the State.
• Must have ability to read, write and follow oral and written directions at a level necessary to accomplish the job.
• Must be able to relate positively and favorably to residents, families, and government regulators, and to work cooperatively with other associates.
• Must be capable of maintaining regular attendance.
• Must be capable of performing the Essential Job Functions of this job, with or without reasonable accommodation.
• Related administrative experience and/or experience as CNA or Nurse at a level necessary to accomplish the job.

Palo Pinto Nursing Center is an equal opportunity employer and give employment and promotional consideration without regard to race, color, sex, religion, age, national origin, marital or veteran status, disability, sexual orientation, gender identity, or any other protected class as defined by local, state, or federal law.

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Ability to commute/relocate:

• Mineral Wells, TX 76067: Reliably commute or planning to relocate before starting work (Required)

License/Certification:

• BLS Certification (Preferred)

Work Location: One location

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