Job Description: Responsible for maintaining, incorporating, and accurately accounting for all medical records information on each individual resident.
Accountability: Medical Records Clerks report to Director of Nursing.
Equipment Used: Computer, typewriter, file cabinets, charts, telephone, copy machine and other various office machines.
Environment: Primarily indoor environment.
Duties and Responsibilities: The employee must be able to perform the essential functions of the job with or without reasonable accommodations. Except as specifically noted, the following functions are considered essential to this position.
Facility Specific Duties and Responsibilities:
10. In-Service training, and assigned QA meetings. May be assigned to chair or make presentations at these events.
11. May be called upon to respond to an admission inquiry; to host a prospective resident or family member; and to visit a prospective resident at home or in the hospital.
12. Is responsible for knowing the relevant state of federal regulations and laws; especially as related to the provision of resident care and documentation.
13. Is to work closely with the Medical Records Consultant. Is expected to be open to suggestions and learning opportunities.
Physical Activity Requirements: Employee is required to use transfer/gait belts or to obtain the assistance of another employee when attempting to assist residents or when lifting or carrying objects in excess of 25 lbs. Employee must be aware that during the normal, routine performance of the essential functions, some of the following body movements may occur naturally, although they may not be a requirement of the job.
Primary Physical Requirements:
Lift up to 10 lbs: Constantly
Lift 11 to 25 lbs: Occasionally
Lift 26 to 50 lbs: Rarely
Lift over 50 lbs: Not required
Carry up to 10 lbs: Constantly
Carry 11 to 25 lbs: Occasionally
Carry 26 to 50 lbs: Not required
Carry over 50 lbs: Not required
Reach above shoulder height: Frequently
Reach at shoulder height: Frequently
Reach below shoulder height: Constantly
Torquing: Not required
Controls and Equipment: Computer, typewriter, filing cabinet, charts, copy machine, and telephone.
Other Physical Consideration:
Twisting: Not Required
Crawling: Not Required
Squatting: Not Required
Kneeling: Not Required
Crouching: Not Required
Climbing: Not Required
Balancing: Not Required
During an 8 hour day, Employee is required to:
Consecutive Hours Total Hours
Sit 2 6
Stand 1 1
Walk 1 1
Work Surface: Varies from tile, linoleum and carpet
Cognitive and Sensory Requirements:
Talking: Not Required
Hearing: Not Required
Tasting and Smelling: Not Required
Access to Personal Health Information:
Licensure/Certification Requirements: LPN
Other Training, skills and experience requirements: Filing, computer skills, knowledge of medical terminology, & keyboarding. Employee must demonstrate on an ongoing basis the ability to develop and maintain good working relationships with co-workers and other departments.
Summary of Occupational Exposures:
Tasks and procedures performed by employee involve risks classified by CDC as:
Category III (Task/activity does not entail predictable or unpredictable exposure to blood.)
Specific Task Exposure:
General Resident Care: Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions, other body fluids – cerebrospinal, synovial, pleural, peritoneal, pericardial, amniotic;
Handling Soiled Linens and Clothing: Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions, other body fluids – cerebrospinal, synovial, pleural, peritoneal, pericardial, amniotic.
Cleaning Resident Rooms and Common Areas – Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions.
Refer to Exposure Control Plan for additional information.
Other Considerations and Requirements: This is an extremely sedentary position where the employee is required to sit for prolonged periods. Employee is able o sit and stand as tolerated. Employee must be organized and detail oriented. Employee may be requested to perform other duties or tasks that are not listed, but are within the competence and training of the individual.