Chart Specialist-Lgmc Health Information Management-Full Time
Employment Status: Full Time
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Preparation Core Competencies:
1. Reconcile paper records with departmental documents to verify receipt of all records.
2. Confirm patient name, medical record number, and account number on every page in the record, front and back.
3. Identify and tape any torn edges.
4. Mount and tape down any sheets less than 8.5 by 11 inches on an 8.5-by-11-inch sheet.
5. For sheets with rhythm strips or other mounted documents, tape down the top of the strip so it does not catch in the automatic document feeder (if you will be scanning in "Portrait" mode).
6. Remove all staples.
7. Put tape over sticky materials.
8. For any documents on card stock or manila, such as Kardex or ambulance run sheets, make a photocopy before scanning.
9. Arrange multipage documents in date order, either chronological or reverse chronological, per department guidelines.
10. Ensure all pages are in the same proper orientation.
11. If a document is identified as likely to result in poor image quality once scanned, photocopy the document, adjusting the copy contrast (lightness/darkness). This may help improve the quality of the scanned image. If improvement is not noted, follow departmental guidelines for processing poor-quality originals.
12. Once all documents are prepped for scanning, bundle them together. Set them aside until you are ready to deliver them to the scanning staff.
Scanning Core Competencies:
1. Perform daily maintenance of the scanner
2. Calibrate the scanner for proper image quality
3. "Fan" the stack of documents to be scanned in order to make sure the documents separate easily and that any previous hole punches or stapled pages do not stick together. Purpose: Reduce the number of automatic document feeder misfeeds.
4. Once records are scanned, remove them from the scanner's out tray. Begin process of verifying the quality and accuracy of the scans. With the records face up, view the hard copy and the scanned image to confirm all images can be read and all pages were captured. This can be done by flipping through the hard copies as you verify each image, page by page. Purpose: Reduce the number of rescans as a result of poor image quality or skipped pages.
5. As images are reviewed, change the rotation, switch sides, etc., as needed. For example, documents that are typically viewed "landscape" should be rotated so they present to the end user in landscape mode. If a document was sent through the scanner so that the back page was scanned as the front page, switch sides to put the images in the appropriate order. Purpose: Improve the readability and use of the images by the end user.
6. If an image is identified to be of poor quality, adjust sensitivity or use the copy machine to enhance the quality of the document to be scanned. Purpose: Reduce the number of records returned for rescan as a result of poor image quality.
Quality Control/Validating Core Competencies
1 Determine the readiness of the batch for the quality control process.
2 Locate the electronic document for verification against the paper batch.
3 Review each image in the batch and verify the following:
a) Correct patient name and FIN
b) Proper indexing level (encounter, section)
c) Image quality (readable, orientation, multiple sides, etc.)
4. For each page scanned or indexed with errors
a) Rearrange out of order images
b) Relocate electronic images that are incorrectly filed in another document
c) Relocate electronic images that have are incorrectly filed in an encounter
d) Replace electronic images that have unacceptable image quality e) modify the indexing as appropriate
Analysis Core Competencies
1 Analyze all encounter types for accuracy and completeness of the medical record.
2 Assign deficiencies to each medical record as appropriate.
3 Performs concurrent and/or discharge analysis on every inpatient, outpatient, emergency room and ambulatory surgery, patient medical record in accordance with JCAHO Standards for completeness and accuracy of documentation.
Birth Certificate Core Competencies
1. Completes a birth certificate for every newborn patient admitted daily.
2. Maintain proficiency in understanding Louisiana Law as it pertains to birth certificate completion.
3. Fax Birth Announcement consent to The Daily Advertiser to meet legal requirements.
4. Route completed birth certificates to physician's office for his/her signature.
5. Download all electronic birth certificates to Vital Statistics through the state's system.
6. Complete hearing screen data information for the Department of Health and Hospitals.
7. Maintains birth log daily.
8. Mail completed birth certificate to the Department of Vital Records.
9. Complete all birth verifications when needed.
Clerical Core Competencies
1 Greets visitors and controls the flow of traffic through the department.
2 Answer all incoming telephone calls and routes them appropriately.
3 Monitors activity of the fax and copy machines and insures proper working conditions.
4 Process and mail copies of dictation to respective physicians.
5 Completes requisitions for in-house request within a fifteen-minute turnaround time.
6 Visits in-house patient as part of requisition completion when an authorization must be completed.
7 Responsible for processing requisitions from outside facilities when the patient is in-house.
Other Core Competencies
1 Pickup all in-house and/or or discharged medical records from the inpatient units and various departments for processing.
2 Research all missing in-house and/or discharged patient charts to assure accuracy of the imaging process.
3 Files all imaged in-house and/or discharged patient charts in the appropriate location for later destruction.
4 Assist physicians during chart completion using the electronic chart completion system when requested by a physician.
5 Print copy of chart for physician requesting paper chart for completion of dictation.
6 Maintain computer error log.
7 Distributes department mail to the appropriate area, as well as sorting of mail generated by the department within the mailroom.
8 Maintains Discharge List in order to account for medical records within Health Information Management.
9 Maintain Discharge List to assure every discharge patient chart is scanned/indexed into imaging system.
10 Verifies accuracy of the admission and discharge lists.
11 Monitors the Cerner system for duplicate CPI numbers and eliminates from the system.
12 Provide funeral homes personnel with time of death and the physician who pronounced the patient.
13 Process/routes dictation to the appropriate medical record.
14 Researches dictation within the transcription and imaging system.
15 Monitors the printer in the transcription area every fifteen minutes for any Pre-op History and Physical that is transcribed.
16 Consistently work quality queues to ensure complete and accurate processing of all transcribed reports. Maintain high quality standards when performing job duties.
17 Completes any special assignment as determined by the Supervisor.
18 Understand the importance of ensuring a complete medical record as a true legal document.
19 Maintains patient confidentiality by following LGMC and HIM department procedure concerning release of information as well as local, state and federal regulations.
20 Respects and practices the Health Information Management Code of Ethics.
21 Upholds the guidelines and continuing education of Corporate Compliance as outlined in the policies and procedures of the HIM Compliance Plan.
22 Equally participates in performing a coworker's duties when absence is required.
23 Adheres to and supports HIM and hospital policies and procedures.
24 Participates in required departmental meetings and in service education.
25 Adheres to Medical/Dental Staff Bylaws for maintaining an accurate, complete and legible medical record.
Experience in health information management department preferred
Good oral communication skills
Basic computer skills preferred
PHYSICAL DEMANDS AND WORKING CONDITIONS:
* Medium Work as defined by the U.S. Department of Labor constitutes a maximum lift of 21-50 pounds on occasion and/or a maximum lift of 11-25 pounds on a frequent basis
* May be required to assist in the turning, lifting, or moving patients as well as walking about from patients' rooms, as well as to and from various hospital areas
Formal application; verification of education, and experience; verification of license(s), certification(s), registration(s), accreditation(s) if applicable; oral interview, reference and background checks; job related tests may be required.
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, skills, and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must comply with all SERVICE Standards of Behavior
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