MEDICAL RECORDS ASSISTANT

California Park Post Acute; Chico (CA); On-site; USD 25,000 - 39,000; Full time

Job summary

California Park Post Acute is seeking a detail-oriented Medical Records Clerk to transcribe physician and nursing orders accurately and enter them into the EMR system. You will maintain resident charts, ensure staff are informed of new orders, and perform chart audits as needed in a fast-paced facility setting.

Ideal candidates will have High School diploma, strong English communication, and prior medical records experience.

Qualifications

• Must be able to read, analyze, and interpret common scientific and technical information, and be easily understood through verbal communication in the English language.
• Previous experience in medical records preferred.

Responsibilities

• Transcribe physician and nursing orders accurately.
• Key information into computer systems, including EMR.
• Ensure staff is aware of new orders and notes as required.
• Maintain resident medical charts and station documents.
• Perform chart audits as assigned.
• Attend survey training and interact with state surveyors as directed.

Skills

Communication skills

Data entry

English language

Attention to detail

Education

High School diploma or equivalent

Tools

EMR

Job description

ESSENTIAL JOB FUNCTIONS:Transcribe, accurately, physician and nursing orders on appropriate documents in a timely mannerKeys information into computer systems, including EMRAssure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as requiredRecord accurate, legible information about resident care and condition in appropriate sections of resident’s recordsFollow facility policies and procedures including those related to infection controlCapable to perform new duties as assigned and trainedMaintain resident medical charts, station documents and suppliesInput physician and nursing orders to computerEstablish and maintain effective communication both written and verbalAble to interact effectively with individuals who are cognitively and/or physically impairedRevision Date: 03/01/14 1Organize nursing stations and maintain a tidy work environmentPerform chart audits as assignedDemonstrate ability to maintain confidentiality of resident and facility informationPrioritize workload and complete projects accurately and in a timely mannerAssist with preparation for state inspections as directed. Attend survey training and interact with state surveyors as directed by immediate supervisorDemonstrate interpersonal skills that contribute to a positive work environmentDemonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactionsProvide excellent service to staff, visitors, and residentsAnswer telephone professionally and in accordance with facility policyDemonstrate competence in use of proper body mechanics for both upper and lower bodyMonitor physical environment for safety or fire hazards and corrects or reports potential problems immediately to Charge Nurse. Promptly reports housekeeping and maintenance problems to Charge NurseReport injury to resident or self to Charge Nurse immediatelyParticipate in fire and disaster drills. In the event of any emergency, carries out assigned duties to assure resident safetyKnowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond to written or oral instruction in case of emergencyAdhere to policies and proceduresQUALIFICATIONS/REQUIREMENTS:Education: High School graduate or equivalentLicense: None RequiredWork Experience: Previous experience in medical records preferredLanguage Skills:Must be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language.Mathematical Skills:Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.Ability to perform these operations using units of weight measurement, and volume.Communication Skills:Must have exceptional communication and customer service skills, and be empathetic.Ability to effectively communicate with patients, families, responsible parties, staff and outside resources and agencies.