Wilbarger General Hospital

Wilbarger General Hospital Vernon, Texas

Job Description

Job Title: Health Information Clerk

Department: Health Information

Job Summary: The Health Information Management (HIM) Department is central to the accuracy and completeness of a patient's health information (PHI) which reflects the service given to the customer during their interaction with Wilbarger General Hospital. That care carries forward in the medical record in format, availability, billing of services, and clinical reference by other caregivers. The HIM Clerk is at the forefront of this service and as such represents Wilbarger General Hospital in interactions with others within and without our facility. The Health Information Management Clerk is responsible for the accuracy, completeness, security, and confidentiality of a patient's medical record as well as the information contained within that record.

Job Qualifications: A. Education: High School Diploma

B. Personal Job-Related Skills: Knowledge of Microsoft Office EXCEL, WORD, and OUTLOOK. C. Licensure, Registry or Certification: None Required D. Experience: 1. Prior work experience: One year work experience in a medical records office setting with knowledge of medical terminology preferred.

2. Technical Training: None E. Physical and Mental Requirements: Duties of the position require intermittent walking, sitting, and standing. Some bending, stooping, and reaching is required with the lifting of items up to a weight of 20 pounds. The ability to comprehend and follow routine written or verbal instructions or directions. F.

Rev 11/21/2014 Essential Duties and Responsibilities: Medical Record Retrieval: Provides authorized individuals with timely access to patient information without compromising the security of the patient records.

Chart Analysis: Reviews patient records for completeness. Staff ensures the presence of provider signatures/initials and the required documentation elements.

Transition: Has demonstrated the ability to accept the continual changes in the Medical Records Department.

Job Associated Equipment: Provides knowledge, care, and maintenance of equipment essential for job functions. Staff will demonstrate working knowledge of the electronic health record and spreadsheet applications in order to comply with requirements.

Failure of Systems: Provides knowledge and understanding of Medical Record's role in case of disaster, power failure, or any other event affecting the availability of the patient's Medical Record.

Other Significant Requirements: 1. Respond to all requests for records in a courteous and timely manner. All requests will follow the HIPPA, Wilbarger General Hospital, and Health Information Management Departmental guidelines for confidentiality and security of that information.

2. The HIM Clerk will conduct analysis of the patient's medical record for completeness and accuracy in a timely manner. Any deficiencies shall be noted in the electronic format, forwarded to the clinician responsible in a courteous and timely manner. A no time is a medical record to be filed for storage with a deficiency unless approved by the Health Information Management Director.

3. The HIM Clerk will assess the capacity of the medical record storage area for ease of placement and retrieval of the medical records. If the ease of retrieval or space becomes limited, the clerk will remove medical records that have reached the retention schedule according to Health Information Management Departmental policy. The medical records shall be removed according to retention policy. Medical records which have not reached the retention deadline will be scanned into the Electronic Health Record for future retrieval. 4. The HIM Clerk will coordinate with the Chief of Medical Staff for clinical reviews of the medical records monthly. At times, surveys will be conducted at Wilbarger General Hospital and the HIM Clerk will be responsible to assist in those surveys.

5. The HIM Clerk shall review transcription for accuracy and completeness. The clinician is responsible for information within the document for accuracy and should be queried by the HIM Clerk for any information which may be incomplete.

6. The HIM Clerk will provide assistance to the Coders and Business Office staff in order to facilitate a timely revenue return.

7. The HIM Clerk will assist the Health Information Management Director as assigned.

STATEMENT OF UNDERSTANDING: I have read and understand the above JOB DESCRIPTION and understand the essential duties outlined and required in this position. I understand that I should contact my Department Manager if I have any questions or concerns regarding the job duties and requirements as outlined above. I acknowledge that I have received a copy of this job description.

Employee Signature Date

Department Manager Signature Date

Rev 11/21/2014