Medical Records Clerk

TITLE: Medical Records Clerk FLSA Status: Non-Exempt

Department: Health Center Operations Reports to: Health Center Manager

Union Exempt: No Date Last Reviewed: 07/22/2024

The following statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. 

Position Summary

Under the supervision of the Health Center Manager, assembles and maintains complete medical records according to established procedures. Files and retrieves patient records; prepares new files; may open and distribute mail.

Essential Duties and Responsibilities

• Sorts and files loose paperwork in patient charts; maintains medical records in proper order. 
• Creates patient folders for new patients using unique identification numbers according to established protocols. 
• Responsible combining non-original charts with original charts;
• Retrieves patient charts on a daily basis for next day appointments and re-files charts in proper sequence; 
• Completes out guides for pulled charts. 
• Locates records that have been checked out or are missing, in accordance with policies for safeguarding patient records. 
• Follows established departmental policies, procedures, and objectives, continuous quality improvement objectives, and safety, environmental, and/or infection control standards. 
• May perform other routine clerical tasks. Is responsible for filing of x-ray, EKG and other reports according to health record order of assembly format;
• Checks for errors in patients identification;
• Pulls and screens health records for completeness, makes patient identification cards and re-files records upon completion of activities;
• Responsible for sending medical records to appropriate destination either through fax, phone, or mail;
• Responsible for charging appropriate fees if any for copies of medical record(s) and submit to Central Billing for further processing;
• Where dental services offered, completes dental charts for medical records;
• Checks encounter forms against medical record to assure conformity, audits medical records to ensure adequate documentation to patient encounter;
• Checks encounter forms against sign-in list to see that no encounter forms are issued;
• Assures that all statistical reporting forms (family and individual registration forms and encounter forms) are checked for accuracy to see that all categories are filled in;
• Maintains daily census from sign-in list;
• Responsible for archiving medical records at the end of the year, by labeling, boxing, and utilizing the computer system to place notes and further research in the future;
• Responsible for purging of health records;
• Obtains and releases medical information as directed by physician;
• Performs miscellaneous job-related duties as assigned. 

MINIMUM EDUCATION AND EXPERIENCE

• High School graduate or GED certificate; 
• Three months related experience;
• Bi-lingual English/Spanish preferred

LICENSES/CERTIFICATIONS REQUIRED

• CPR Certification within 6 months of hire.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED

• Ability to work as a team member within a clinical environment. 
• Records maintenance skills. 
• Ability to develop and maintain filing systems. 
• Ability to complete routine paperwork. 
• Ability to maintain confidentiality of records and information. 
• Skill in the use of operating basic office equipment. 
• Ability to follow routine verbal or written instructions. 
• Ability to maintain quality, safety, and/or infection control standards. 
• Ability to maintain patient confidentiality.

Age of Patients Served

• None

PHYSICAL CHARACTERISTICS/WORKING CONDITIONS

A person in this position has sufficient time to complete most tasks although under pressure depending on patient and organization demands. There are frequent opportunities to relax from any physical exertion or to change position in work activities.

• Physical Effort and Dexterity: Good dexterity to operate personal computer and office equipment. Occasional lifting and carrying related to office duties. 
• Machines, Tools, Equipment required to be operated: Capable of using office machines and personal computers for word processing, data entry and spreadsheet applications.    
• Visual Acuity, Hearing, and Speaking: Must be able to read a computer monitor and outputs accurately. Must be able to communicate clearly and accurately for work and safety compliance.
• Environment/Working Conditions: Work is mostly inside an office in a controlled environment. Normal office safety precautions and practices are required. Position requires travel throughout the Albuquerque metropolitan area. Work regularly scheduled Monday-Friday, although weekends may be required to meet deadlines