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Medical Records Clerk


Job Title: Medical Records Clerk

Department: Health Information Management

Reports To: Health Information Management Director


Summary: Reviews medical records after discharge for completeness in compliance with the hospital’s bylaws and state requirements.  Coordinates record review and assists requesters with access to and release of information.  Responds to requests for medical information by performing duties in accordance with established hospital and departmental policy and state and federal laws.   Processes incoming and outgoing mail on a daily basis.


Essential Duties and Responsibilities include the following: Other duties may be assigned.


  • Collects all discharged patient charts from the patient care units on a daily basis.

  • Collects loose filing for those discharged charts and inserts such filing in the proper chart.

  • Combines the current patient chart with any previous patient discharges for a unit record.

  • Assemble discharged patient charts according to chart order.

  • Places assembled chart in the proper folder according to the medical record number.

  • Analyzes medical records of discharged patients for completeness and accuracy according to department and hospital policy and procedures.

  • Flags charts for deficiencies.

  • Forwards analyzed charts to the coder.

  • Performs performance improvement audits on each chart as directed by the director.

  • Responsible for coordinating the release of medical information to all requesters, including patients, physicians, other healthcare providers, insurance companies, and attorneys.

  • Responsible for processing subpoenas and court orders.

  • Verifies authorization in accordance with hospital policy and procedure and state and federal laws.

  • Maintains a release of information log.

  • Maintains hospital requirements, policies, and standards on confidentiality.

  • Responsible for maintaining regulatory requirements of licensure.

  • Maintains a good working relationship within the department, with other departments, and with the medical staff.

  • Willing to accept additional assignments.

  • Answers phone in a professional and courteous manner; takes messages; routes calls to appropriate staff members.

  • Performs clerical work as needed:  filing, pulling charts, etc.

  • Adheres to dress code; appearance is neat and clean.

  • Completes annual education requirements.

  • Maintains regulatory requirements.

  • Always maintains patient confidentiality.

  • Reports to work on time and as scheduled and completes work within the designated time.

  • Wears identification while on duty and uses computerized punch time system correctly.

  • Represents the organization in a positive and professional manner.

  • Actively participates in performance improvement and CQI activities.

  • Complies with all organizational policies regarding ethical business practices.

  • Communicates the mission, ethics, and goals of the facility, as well as the focus statement of the department.

  • Performs any other duties as required or requested by the Supervisor.

Job Requirements:                                                   

  • High school graduate or equivalent.      

  • One (1) or more years of previous similar hospital experience as a Coder.

  • Knowledge of state charting requirements.

  • Ability to work with physicians in a collaborative manner.

  • Ability to read and communicate effectively in English.

  • Basic computer knowledge.


Physical Demands:                                                   

Including vision, hearing, and repetitive motion.  Must sit for long periods of time.


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