Job Description

Summary

The Document Imaging Technician scans the paper medical records, prepares them for scanning, and scans batches and documents to create an electronic paper record. The Document Imaging Technician monitors the manual indexing queue of unassigned images and reviews each electronic image in the batch. The Document Imaging Technician is responsible for mobile scanning on all nursing units, Surgical Services areas, and Cardiac Cath.

Essential Duties and Responsibilities

1. Prepping

a. Record Reconciliation

• Reconcile the paper medical records with the hospital census to verify receipt of all records.

b. Patient Information Verification

• Confirm the patient’s name, medical record number, and account number on every page in the chart, front and back.
• Add patient stickers to any forms missing demographic information.

c. Document Review and Quality Assurance

• Review the scanned information versus the paper documents to ensure all documents are readable, in the correct order, and that the right side of the document has been scanned.
• Examine the quality of each page and stamp illegible documents with the “Poor Quality Original” stamp.
• Ensure all pages are in the same and proper direction.

d. Document Preparation

• Repair forms as needed such as torn, wrinkled, folded, and dog-eared pages.
• Remove all staples and paper clips.
• Identify and separate multi-part forms with the original being kept.
• Separate and sequence perforated forms for the scanning process.
• Revise non-standard documents so they can be processed by the scanner (i.e. tape small paper or post-it notes onto letter sized paper).
• Print cover sheets for the proper patient and account number and add them to the chart to create a batch.

2. Scanning

a. Scanner Setup and Maintenance

• Perform daily maintenance of the scanner.
• Calibrate the scanner for proper image quality.

b. Batch Processing

• Load batch correctly into scanner, adjust guides, and start scan.
• Visually monitor batches and documents in the viewer and verify image quality and barcode recognition during the scanning process.
• Determine the need to stop or continue processing the batch.
• Acknowledge paper jams, rectify problems, correct batch, and restart the scanning process (if not done correctly, the page could be lost in the electronic paper record).

c. Post-Scanning Activities

• Reorganize the batch after scanning and prepare it for the quality control process.
• Maintain record storage area so folders are neat, orderly, and accessible for quality control prior to destruction.

d. Performance Standards

• Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate.
• Understand and utilize the department computer system in an effective and proficient manner.
• Adhere to Chesapeake Regional Medical Center’s confidentiality policy for all information related to patients, family, hospital employees, physicians, and clients.

3. Indexing

a. Queue Monitoring and Processing

• Monitor the manual indexing queue of unassigned images.
• Prioritize the batches in the queue and retrieve the batches for processing.
• Review each electronic image in the batch.

b. Patient and Document Identification

• Determine the correct patient name, medical record number, account number, and document type for each image.

c. Image Review and Disposition

• Review and determine if the image should:
• Be added as a new document
• Replace a page within an existing document
• Replace an entire document
• Be deleted

d. Image Indexing

• Index the image record appropriately by selecting the correct patient, medical record number, and encounter.
• Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate.

4. Medical Record Processing

• Interacts with nursing, surgical technicians, and unit secretaries to ensure the most current paper work is scanning into the patient record within 24 hours. History and physicals are particularly time sensitive.
• Must have a clear understanding of the medical record and documentation requirements.

Service Excellence Expectations

1. Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center.
2. Exhibit excellent customer relations to patients, visitors, physicians, and co-workers.
3. Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties.
4. Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting positive work and customer environments.
5. Work as a team to continuously improve work quality.
6. Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care.
7. Present self in a positive manner as reflected by personal attire and etiquette.
8. Attend required hospital-wide orientations, meetings, and in-services.

Reporting Structure

Reports to: HIM Operations Manager

Supervises: None

Responsibilities: N/A

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Minimum Required Education

• High school diploma or equivalent

Preferred Education

• Associate’s degree in Health Information Technology

Experience

• 3 to five years in a hospital’s Health Information Department or in a physician’s office

Additional Qualifications

Qualified applicants must have extensive working knowledge of medical terminology and patient record content and format for inpatients and outpatients.