Coordinates and maintains the flow of the medical record and throughout the continuum of care, during the post-discharge period for the completion of the record, and in order to assist unit/department staff with the disposition of the medical record. Assists with assembling/ analysis of discharged records per hospital policies related to timeliness putting the chart in order per departmental guidelines. Hospitals operating with EHR will review record in HCS to ensure all components of the record are complete. Discharged patient records are reviewed for completeness in compliance with the accrediting organizations standards, state, and CMS. Assures that patient abstracts are correctly entered in the HCS Deficiency System and/or Deficiency List maintained by HIM.

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Collects all discharged patient medical records from all units and Outpatient. For Hospitals operating full Electronic Health Record (EHR) collect daily miscellaneous paper documents for scanning to patients file in EHR.
• Collects loose filing for those discharged patient medical records and inserts such filing in proper medical record.
• Assembles discharged patient medical records according to hospital chart order.
• Places assembled medical record in proper folder according to medical record number.
• Analyzes medical records of discharged patients for completeness and accuracy according to departmental and hospital policy and procedures and regulatory agencies.
• Completes deficiencies list in HCS and/or Deficiency List Form.
• Understands the medical records filing system Terminal Digit Order and/or Straight Numeric.
• For Electronic Health Records--discharge patients will be reviewed and analyzed to ensure all components are complete in the record (in place of assembling paper record).
• Must be familiar with performance improvement data collection and documentation.
• Pulls medical records requested for various clinical departments and performance improvement.
• Assists in answering the telephone and taking accurate messages.
• Must be familiar with medical record requirements for Behavioral Health.
• Protects the security and confidentiality of the medical record.
• Maintains a good working relationship within the department and other departments.
• Serves as an internal and external resource between departments, outside entities, and individuals to ensure protected health information is received, maintained and disclosed in compliance with HIPAA and 42 CFR Part 2.
• Functions as a team member in the Release of Information process.
• Serves as support for the processing, distributing, and maintaining of dictated reports.
• Prepares records for scanning according to departmental guidelines and scans records into HCS. (if applicable).
• Maintains a working knowledge of the record retention process in order to remain in compliance with governmental, accrediting, regulatory, and organization requirements.

• Perform other duties as assigned.

Safety (15% of performance review)

• Strives to create a safe, healing environment for patients and family members
• Follows all safety rules while on the job.
• Reports near misses, as well as errors and accidents promptly.
• Corrects minor safety hazards.
• Communicates with peers and management regarding any hazards identified in the workplace.
• Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
• Participates in quality projects, as assigned, and supports quality initiatives.
• Supports and maintains a culture of safety and quality.

Teamwork (15% of performance review)

• Works well with others in a spirit of teamwork and cooperation.
• Responds willingly to colleagues and serves as an active part of the hospital team.
• Builds collaborative relationships with patients, families, staff, and physicians.
• The ability to retrieve, communicate, and present data and information both verbally and in writing as required
• Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
• Demonstrates adequate skills in all forms of communication.
• Adheres to the Standards of Behavior

Integrity (15% of performance review)

• Strives to always do the right thing for the patient, coworkers, and the hospital
• Adheres to established standards, policies, procedures, protocols, and laws.
• Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
• Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
• Completes required trainings within defined time periods.
• Exemplifies professionalism through good attendance and positive attitude, at all times.
• Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
• Ensures proper documentation in all position activities, following federal and state guidelines.

Compassion (15% of performance review)

• Demonstrates accountability for ensuring the highest quality patient care for patients.
• Willingness to be accepting of those in need, and to extend a helping hand
• Desire to go above and beyond for others
• Understanding and accepting of cultural diversity and differences

Education

• Required: High school diploma or GED.
• Preferred: Some college courses
• Maintains education and development as appropriate for position.

Experience

• Required: Two (2) or more years of previous hospital experience.
• Preferred: A minimum of one (1) year of experience in a behavioral setting.