The work involves responsibility for the performance of technical activities involved in the analysis of medical records for completeness, consistency and compliance with facility policy and standards of accrediting and regulatory agencies. The incumbent in this class performs related functions such as coding medical record information and selecting and compiling medical record data. Positions in this class are characterized by the performance of technical medical records activities requiring the application of a practical knowledge of medical terminology, anatomy, physiology, the internal organization and consistency of the medical record, medical record references and procedures and the medical and legal significance of medical records. The incumbent may supervise a small number of clerical support personnel engaged in the collection, analysis, routine coding, maintenance and retrieval of the facility's medical records. Does related work as required.
Reviews and analyzes medical records to insure that the records meet the requirements of accrediting agencies and legal requirements, needs for future treatment of the patient and are adequate for research and training purposes.
Determines that the necessary components of the medical record are present and complete; that the terminology used by physicians is in keeping with accepted nomenclature; that the contents of the record appear to be accurate and internally consistent; and that the record appears to be complete enough to furnish desired data for current and future use.
Codes diseases, procedures and special therapy according to recognized nomenclature and classification systems.
Collects and compiles data, or supervises the collection and compilation of data from the records for regular and special statistical reports and studies, including official reports to State and Federal agencies.
Provides advice and assistance to clinical staff and/or health care personnel on medical record matters including records contained in automated patient information systems.
Participates in staff meetings and serves on the medical record committee or other committees as required.
May supervise clerical support staff engaged in the collection, analysis, routine coding, maintenance and retrieval of medical records.
WHEN ASSIGNED TO THE ONONDAGA COUNTY HEALTH DEPARTMENT:
Participates in public health preparedness activities as trained and assigned.
Utilizes appropriate methods for interacting effectively and professionally with persons of all ages and from diverse cultural, socioeconomic, educational, racial and ethnic backgrounds, sexual orientations, lifestyles and physical abilities.
Good knowledge of the principles, methods and practices of modern medical record library science.
Good knowledge of medical and anatomical terminology and of disease etiology required for the proper classification, maintenance and custody of medical case records.
Working knowledge of the uses and limitations of primary and secondary medical records, indices and classification systems.
Working knowledge of pertinent Federal, State, departmental and accrediting agency, legal and policy requirements, and regulations relating to the maintenance and release of medical records information.
Working knowledge of coding and indexing related to the standard nomenclature of psychiatric or medical diagnoses.
Working knowledge of departmental policies and procedures.
Working knowledge of the types of information contained in the department's automated patient information system, and of procedures for gaining access to the system.
Ability to analyze medical records.
Ability to apply coding and indexing systems to medical records.
Ability to prepare routine and special tabulations, analyses and presentations.
Ability to recognize inconsistencies and omissions in medical records.
Ability of instruct staff in activities related to the maintenance of complete and accurate medical records.
Registration with the American Health Information Management Association (AHIMA) as an accredited Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT).