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Medical Records Technician

The incumbent is responsible for; (1) providing administrative support for the Medical Center Medical Records Committee, (2) abstraction of clinical information for ongoing regulatory reviews, and (3) advising the clinical treatment team on issues related to record completion and documentation requirements.
(4) assisting with processing legal requests for records and/or testimony from VA Regional Counsel and third party lawyers.
(5) Serves as backup to the Release of Information Clerks.
The incumbent is responsible for the following functions:
Downloads and prepares lists of records with deficiencies using the Vista TIU, CPRS, and IRT packages.
Validates data collected, creates status reports including trended data for review by clinical care lines to assist with record completion, and for review by Medical Center Management for regulatory review and reporting.
Monitors delinquent list for follow up purposes on necessary documents (i.
e.
, operation reports, discharge summaries, etc.
) that are needed for completion of medical records.
Works with the patient treatment teams to identify correct responsible clinicians for documentation.
Receives and enters data into VistA in order to track delinquent or incomplete medical records.
Contacts physicians and other ancillary service personnel regarding dictation and/or signatures.
Assists medical staff by providing information as to required documentation.
Communicates very closely with the medical staff to answer questions and resolve problems to insure quality documentation in the medical records.
Prepares reports of unsigned documents for distribution to appropriate service lines (i.
e.
, Medicine, Acute Care, Mental Health, Extended Care & Rehabilitation Care, etc).
Monitors delinquent dictation list for follow up purposes on necessary documents (i.
e.
, operation reports, discharge summaries, etc.
) that are needed for completion of medical records.
Notifies appropriate physician and other personnel of the status of dictation.
Monitors housestaff rotation schedule and contacts resident housestaff to insure completion of records prior to departure from this Medical Center.
Utilizes basic knowledge of medical terminology, anatomy and physiology, and ICD 9 CM coding to research and collect information for various medical studies and research projects utilizing the Patient Treatment File (PTF).
Assists with release of information from patients' records when expertise is needed, or when backlog warrants.
Conducts periodic audits of records processing activities.
Participate in approved quality improvement focused reviews.
Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements, and to satisfy current Medical Center performance measures.
Assists with capture and reporting of documentation deficiencies as needed including downloading data and creating trended reports.


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