MEDICAL RECORDS ASSISTANT

ESSENTIAL JOB FUNCTIONS:
Transcribe, accurately, physician and nursing orders on appropriate documents in a timely manner
Keys information into computer systems, including EMR
Assure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as required
Record accurate, legible information about resident care and condition in appropriate sections of residents records
Follow facility policies and procedures including those related to infection control
Capable to perform new duties as assigned and trained
Maintain resident medical charts, station documents and supplies
Input physician and nursing orders to computer
Establish and maintain effective communication both written and verbal
Able to interact effectively with individuals who are cognitively and/or physically impaired

Organize nursing stations and maintain a tidy work environment
Perform chart audits as assigned
Demonstrate ability to maintain confidentiality of resident and facility information
Prioritize workload and complete projects accurately and in a timely manner
Assist with preparation for state inspections as directed. Attend survey training and interact with state surveyors as
directed by immediate supervisor
Demonstrate interpersonal skills that contribute to a positive work environment
Demonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactions
Provide excellent service to staff, visitors, and residents
Answer telephone professionally and in accordance with facility policy
Demonstrate competence in use of proper body mechanics for both upper and lower body
Monitor physical environment for safety or fire hazards and corrects or reports potential problems immediately to
Charge Nurse. Promptly reports housekeeping and maintenance problems to Charge Nurse
Report injury to resident or self to Charge Nurse immediately
Participate in fire and disaster drills. In the event of any emergency, carries out assigned duties to assure resident
safety
Knowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond to
written or oral instruction in case of emergency
Adhere to policies and procedures

JOB FUNCTIONS:
Demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions
Appreciates the importance of maintaining confidentiality of resident and facility information
Demonstrate honesty and integrity at all times in the care and use of resident and facility property
Must be able to key information into computer systems
Good communication skills both verbal and written
Proficient in English
Able to understand and follow written and verbal directions
Working knowledge of basic computer programs: Word and Excel
Basic and advanced typing
Basic and advanced filing

Working knowledge of medical terminology

Open, flexibility to changing needs of the Medical Records Department
Other duties as assigned

Qualifications

QUALIFICATIONS/REQUIREMENTS:
Education: High School graduate or equivalent
License: None Required
Work Experience: Previous experience in medical records preferred
Language Skills:
Must be able to read, analyze, and interpret common scientific and technical information, and to be easily
understood through verbal communication in the English language.
Mathematical Skills:
Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common
fractions, and decimals.
Ability to perform these operations using units of weight measurement, and volume.
Communication Skills:
Must have exceptional communication and customer service skills, and be empathetic.
Ability to effectively communicate with patients, families, responsible parties, staff and outside resources and
agencies.