Medical Records

Conduct routine audits of in-house charts upon admission and quarterly to ensure completeness and accuracy. Provide notification to staff on deficiencies and follow up to ensure records are complete. Assemble medical records for discharged residents, analyze charts for completeness, and process requests for medical information including subpoenas. Maintain the Release of Information Log, complete Accounting of Disclosures forms per HIPAA, and monitor physician visits for non-compliance. Purge charts, maintain destruction logs, and coordinate with the off-site storage facility. Assign ICD-9 CM codes, input data into the HCS system, and coordinate physician dictation with transcription companies. File loose sheets, maintain department supplies, and complete discharge/transfer notices. Serve as the facility contact for Record Retention and Destruction Policy, working with departments to box documents for long-term storage.