Health Information Management Technician - Adult Cardiology Assoc BR

The HIM Technician 1 organizes patient medical records.  Prepares/arranges records while assuring the accuracy of the documents.  May scan records into an electronic format, relying on technical skills and knowledge of commonly-used concepts, practices and procedures within a particular field.  Performs quality review to assure quality of legal electronic medical record.  The position relies on established guidelines to accomplish tasks and works under close supervision.  

1. Medical Records Preparation/Scanning
   1. Responsible for the preparation and arrangement of the medical record in accordance with the established chart order. The following items are crucial during the preparation process: the verification of each patient's medical record number (MRN), the identification of H&P within 30 days, the separation of documents into two sections (non-bar-coded and bar-coded), the distinction between Acute to Rehab and Acute to TCU transfer charts, identifying items that are maintained in the medical record from outside sources, the repair of damaged documents, the removal of carbons, staples, clips, etc., placing all documents in reverse chronological order, and the initialing/ dating of the batch header.
   2. Responsible for scanning the paper chart into the Chartmaxx system in order to achieve an electronic medical record. The person scanning must adhere to the following performance indicators: verify that the batch header matches the patient face sheet, all four (4) corners of the documents are captured in the image, the correct batch type selected (i.e. inpatient, loose, etc.) the EKG(s) included with the chart are appropriately scanned and placed to the back, the batch header is initialed/dated, and the correct batch ID is assigned to the record. Any illegible documents must be rescanned into the system to complete the legal medical record.
2. Quality Review
   1. Responsible for meeting criteria and maintaining a quality rating between 90% to 100% for all work performed within the Health Information Management Department.
3. Medical Records Duties
   1. Responsible for verifying that all pages in the paper chart correlates to the electronic medical record in the Chartmaxx system. In addition to assigning the correct name to the document; ensuring the correct orientation of all pages in the record; deleting all blank and duplicate documents; verifying that all (labeled) pages in the record match the demographic information on the facesheet or batch header, and the correct initials and dates on the batch header. All batches are immediately uploaded into the Chartmaxx system upon completion.
   2. Maintains a good understanding of the following functions: retrieval of the medical record in paper and electronic form; knowledgeable in the reconciling/updating of discharged patient records; and completing the pickup of patient charts from nursing services.
4. Other Duties as Assigned
   1. Performs other duties as assigned or requested.