Medical Records Secretary Job Summary:
The Medical Records Secretary is responsible for reviewing medial records for completeness and computerizations of medical records and reports. Keeps current medical records thinned according to procedure. Responds to the inquiries of family residents, visitors and following procedure at nurses’ stations. Arranges for transportation, families, or volunteers as needed for resident appointments. Answers or responds to call lights and exit alarms. Prepares medical chart and lab orders as required. Completes medical supply list for restocker. Accurately files information in chart.
Division: Nursing Home
Location: 1115 4th Ave N Sauk Rapids, MN 56379
- Responsible to review medical records for completeness and computerize and run reports.
- Reviews audit sheets and maintains follow-up of records with deficiencies until record is complete.
- Keeps current medical records thinned according to procedure.
- Responds to inquiries of family, residents, visitors and staff.
- Answers phones promptly and courteously.
- Triages phone calls.
- Gives directions and information as needed.
- Responsible for maintaining medical records and performing clerical duties at the nurses stations following procedures.
- Makes appointments for residents and prepares paperwork for appointments.
- Arranges for transportation, families or volunteers, as needed for resident appointments according to procedure.
- Answers call lights and exits alarms promptly.
- Answers and acknowledges call light promptly and summons appropriate staff.
- Investigates exit alarms by informing appropriate staff, watching monitor or going to exit.
- Prepares medical charts and lab orders as required.
- Completes medical supply list for restocker.
- Arranges physician rounds with medical clinics in compliance with regulation requirements.
- Prints orders to be signed by physician on rounds.
- Prepares charts for physician rounds.
- Track physician’s orders, discharge summary and history and physical information.
- Sends fax as needed to pharmacy and to clinics.
- Accurately files information into chart.
- Adds admission information to medical record.
- Keeps all information updated pertaining to medical records.
- Transcribe physician orders on admission, return from hospital and after physician rounds.
- Prepares change overs each month for nursing to review and utilize.
Performs other duties as assigned by the Health Information Manager.
- Must have clerical skills such as typing and computer skills.
- Must have the ability to work in a variety of work areas.
- Familiarity with medical terminology required.
- Must have excellent customer service skills.
- Experience with ICD coding and/or as an LPN preferred.
Hours: Full-time Days
On-Call Rotation: No
Weekend/Holiday Rotation: NoApply Online