MEDICAL RECORDS ADMINISTRATOR
The work involves responsibility for managing, organizing and supervising a facility's medical record program and evaluating and modifying medical record systems to meet particular needs. Duties include developing and implementing a system for acquiring, analyzing, coding, storing and retrieving detailed patient medical records in accordance with facility goals and standards of accrediting and regulatory agencies. Basic medical records under control of the Medical Records Administrator consist of individual patient files containing such information as medical history, admission, diagnosis, prognosis, treatment, progress, transfer and discharge. Positions in this class are characterized by the performance of a full range of professional medical records activities requiring the application of the theories and techniques of medical records library science in the development, maintenance, analysis and use of diagnostic and therapeutic medical records. The incumbent provides advice and consultation to facility management and staff members on medial record problems and procedures. The classification of Medical Records Administrator differs from that of Medical Records Technician in that the latter does not have responsibility for the supervision and training of support staff engaged in the analysis, coding, and retrieval of the facility's medical records, and does not perform related administrative duties such as establishing policies and procedures, planning and initiating projects, maintaining quality standards of the departmental work and selecting and recommending equipment and supplies. Supervision is received from a Facility Administrator who allows the incumbent wide latitude in the control and management of the medical record system. Supervision is exercised over a clerical support staff. Does related work as required.
Plans and develops medical record retention, preservation and retrieval systems in accordance with facility goals and standards of accrediting and regulatory agencies.
Determines, in conjunction with facility management and professional staff, appropriate methodology and standard classification and indexing best suited to the facility's needs.
Develops, promulgates, and revises medical record goals, procedures and guidelines as needed.
Analyzes the utilization of medial records and designs systems to improve their usefulness.
Supervises, assigns, reviews and evaluates work of subordinates engaged in the collection, analysis, coding, maintenance and retrieval of the facility's medical records as well as providing procedural guidelines and technical assistance.
Provides training to facility staff on proper work procedures and techniques, answers questions and assists in solving problems.
Reviews and analyzes medical records to ensure that the records meet the requirements of accrediting agencies, meet legal requirements, and meet needs for future treatment of the patient.
Determines that the necessary components such as progress notes, nurses' notes, laboratory reports and treatment records 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 filed in an established sequence; and that all omissions are noted.
Codes or supervises the coding of diseases, surgery and special therapy according to recognized nomenclature and classification systems; Selects the most accurate and descriptive code from the appropriate system.
Supervises the collection and completion of data from the records for regular and special statistical reports and studies, including official reports for State and Federal agencies.
Provides advice, consultation and assistance on medical record matters to facility management and staff by serving as a member of the Medical Records Committee and Utilization Review Committee, advising clinical supervision on medical record policy and procedures and instructing treatment staff in proper methods of entering observations and progress notes in medical records.
WHEN ASSIGNED TO THE ONONDAGA COUNTY HEALTH DEPARTMENT
Participates in public health preparedness activities as trained and assigned.
Good knowledge of the principles, methods and practices of modern medical record library science and their application to health care facility situations.
Good knowledge of medical and anatomical terminology and of disease etiology required for the proper classification, maintenance and custody of medical case records.
Good knowledge of pertinent Federal, State, Departments, 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 medical or psychiatric diagnosis.
Working knowledge of facility policies and procedures.
Working knowledge of the practice and techniques of supervision.
Working knowledge of the mechanical and electronic techniques for processing medical records information.
Ability to plan, assign and supervise the specialized and routine technical and clerical activities of subordinates.
Ability to apply coding and indexing systems to medical records.
Ability to analyze medical records and to prepare routine and special tabulations, analyses and presentations.
Ability to establish and maintain effective working relationships with subordinates clinical staff, physicians and other facility personnel.
Ability to recognize inconsistencies and omissions in medical records.
Ability to instruct facility staff in activities related to the maintenance of complete and accurate medical records.
Physical condition commensurate with the demands of the position.
Registration with the American Health Information Management Association (AHIMA) as an accredited Registered Health Information Administrator (RHIA).
NOTE: Registration with the American Health Information management Association (AHIMA) as an accredited Registered Health Information Technician (RHIT) cannot substitute for the qualification defined above.