Organize, maintain, and update patient health records, ensuring all necessary documentation is included.
Ensure that medical records are accurate, complete, and compliant with legal and regulatory requirements.
Input and update patient information into Electronic Health Record (EHR) systems, ensuring accuracy and confidentiality.
Data Entry and Retrieval:
Review and verify patient data for accuracy, completeness, and compliance with hospital or clinic policies.
Retrieve and prepare medical records as needed for physicians, nurses, and other healthcare providers.
Process patient chart requests and ensure timely delivery of medical information in accordance with policies.
Confidentiality and Security:
Ensure all medical records are kept confidential in compliance with HIPAA (Health Insurance Portability and Accountability Act) and other privacy regulations.
Safeguard patient data and ensure all electronic records are secure from unauthorized access or data breaches.
Quality Control and Auditing:
Conduct regular audits of patient records to ensure accuracy, completeness, and compliance with hospital standards and regulatory requirements.
Identify discrepancies in medical records and work with healthcare providers to correct or update any errors.
Maintain record-keeping standards and ensure proper organization and retention of files.
Coding and Billing Support:
Assist with the assignment of ICD-10 codes, CPT codes, and other classifications used for medical billing and insurance purposes.
Ensure medical records are appropriately coded to ensure accurate billing and reimbursement.
Collaboration and Communication:
Work closely with healthcare providers to ensure proper documentation and filing of medical records.
Communicate with medical staff and other departments to facilitate the completion and submission of necessary documents and reports.
Compliance with Regulations:
Stay up-to-date on federal, state, and local healthcare regulations, ensuring the facility's medical records practices remain compliant.
Assist in the preparation of documentation for regulatory audits and inspections.
Training and Education:
Provide training to new staff members or departments on proper documentation and record-keeping protocols.
Participate in continuing education and professional development to stay current with industry best practices.