Medical Records (86723)

Maintain and update residents' clinical records daily in a confidential, systematic manner adhering to OBRA guidelines and state standards. File documents, enter new admits and discharges into logs, and track outgoing telephone orders while thinning active charts by census. Audit records for new and discharged residents, close out files, and maintain destruction logs for storage. Send monthly compliance letters to physicians, maintain HIPAA logs, and complete QA forms for required meetings. Report findings during morning meetings and assist in emergency evacuations. Order office supplies and update forms as changes occur. Actively participate in resident care enhancement and staff recruitment, training, and retention. Perform other duties as assigned by the Administrator or Director of Nursing.