MEDICAL RECORDS ASSISTANT

Almond Vista Healthcare Center; Modesto (CA); On-site; USD 38,000 - 50,000; Full time

Job summary

Almond Vista Healthcare Center seeks a Medical Records Clerk to accurately transcribe physician and nursing orders, enter data into EMR, and maintain resident charts. Responsibilities include ensuring staff are informed of new orders, upholding confidentiality, and supporting state inspections as directed.

A high school diploma is required, with preference for prior medical records experience. Proficiency in Word/Excel and strong English communication are essential, with good organizational and

Qualifications

• Must read, analyze and interpret common information, and communicate clearly in English.
• Proficient in basic and advanced typing.
• Excellent written and verbal communication with patients, families, staff and outside resources.

Responsibilities

• Transcribe physician and nursing orders accurately and timely.
• Enter information into EMR and maintain resident medical charts.
• Ensure nursing staff are informed of new orders and notes.
• Maintain confidentiality of resident and facility information.

Skills

Typing (basic & advanced)

English proficiency

Communication skills

Medical terminology

Computer literacy

Education

High School diploma or equivalent

Tools

Microsoft Word

Microsoft Excel

Job description

DescriptionESSENTIAL JOB FUNCTIONS:• Transcribe, accurately, physician and nursing orders on appropriate documents in a timely manner• Keys information into computer systems, including EMR• Assure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as required• Record accurate, legible information about resident care and condition in appropriate sections of resident’s records• Follow facility policies and procedures including those related to infection control• Capable to perform new duties as assigned and trained• Maintain resident medical charts, station documents and supplies• Input physician and nursing orders to computer• Establish and maintain effective communication both written and verbal• Able to interact effectively with individuals who are cognitively and/or physically impaired• Organize nursing stations and maintain a tidy work environment• Perform chart audits as assigned• Demonstrate ability to maintain confidentiality of resident and facility information• Prioritize workload and complete projects accurately and in a timely manner• Assist with preparation for state inspections as directed. Attend survey training and interact with state surveyors asdirected by immediate supervisor• Demonstrate interpersonal skills that contribute to a positive work environment• Demonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactions• Provide excellent service to staff, visitors, and residents• Answer telephone professionally and in accordance with facility policy• Demonstrate competence in use of proper body mechanics for both upper and lower body• Monitor physical environment for safety or fire hazards and corrects or reports potential problems immediately toCharge Nurse. Promptly reports housekeeping and maintenance problems to Charge Nurse• Report injury to resident or self to Charge Nurse immediately• Participate in fire and disaster drills. In the event of any emergency, carries out assigned duties to assure residentsafety• Knowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond towritten or oral instruction in case of emergency• Adhere to policies and proceduresJOB FUNCTIONS:• Demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions• Appreciates the importance of maintaining confidentiality of resident and facility information• Demonstrate honesty and integrity at all times in the care and use of resident and facility property• Must be able to key information into computer systems• Good communication skills both verbal and written• Proficient in English• Able to understand and follow written and verbal directions• Working knowledge of basic computer programs: Word and Excel• Basic and advanced typing• Basic and advanced filing• Working knowledge of medical terminology• Open, flexibility to changing needs of the Medical Records Department• Other duties as assignedQualificationsQUALIFICATIONS/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 easilyunderstood 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, commonfractions, 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 andagencies.