10/12/1994 39020

MEDICAL RECORDS DIRECTOR

DEFINITION: This is administrative work planning and directing the operations of the medical records department in a state facility.

An employee in this class directs the facility department that is responsible for the establishment, classification and maintenance of medical records and documents. This employee develops and implements facility policies and procedures required to ensure proper medical records completion and maintenance and compliance with accrediting/certifying agencies' requirements. Work requires a high degree of accuracy due to the frequency of multiple classification or cross references in a single case. Duties include supervision of a clerical/technical staff engaged in the maintenance of complex medical case histories. Work is performed under the direction of an administrative supervisor and is reviewed for compliance to departmental and facility polices and procedures through reports, conferences and inspections.

EXAMPLES OF WORK:vDirects the daily operations of the medical records department in a state facility.

Reviews medical records for completeness and accuracy and refers incomplete or inaccurate records to attending physicians for correction; obtains necessary signature, laboratory and x-ray reports, electrocardiograph tracings, necropsy, pathology, and all other reports in order to complete records and as the records relate to medicolegal documentation issues in conjunction with risk management and quality assurance.

Conducts a continuous review of the facility's policies and procedures related to medical records and develops new or revised policies to assure compliance with state regulations and standards set by the Joint Commission on Accreditation of HealthCare Organizations, Health Care Financing Administration, Accreditation Council on services for people with Developmental Disabilities, and the Federal and State Government for Medicare and Medical Assistance programs, as appropriate.

Codes or verifies the coding of diseases, operations, special therapies and program services and treatments with diagnostic related group assignment according to standard nomenclature and classification systems.

Supervises medical records students participating in an approved MRT program and Health Records Administration.

Supervises and participates in the work of filing, withdrawing, and issuing records and files to authorized personnel.

Supervises and participates in indexing and cross-indexing information contained in medical records.

Searches medical records to make abstracts of pertinent

information; forwards abstracts to authorized personnel.

Prepares or supervises the preparation of periodic reports on such subjects as diagnoses, prognoses, morbidity, mortality and birth; utilization of facility beds according to professional services, and other reports peculiar to the needs of the facility.

Presents medical records in court cases involving subpoena/extra Order of the Court of facility medical records.

Extracts information from medical records for researchers and physicians for use in projects or staff conferences.

Supervises the release of information to physicians, representatives of insurance companies and others who have a legitimate interest in case histories.

Instructs employees in indexing and filing methods, preparation and arrangement of medical information, medical terminology and the nomenclature and classification of diseases; instructs facility medical staff in nomenclature, classification of diseases, treatments and program services and use of medical records.

Serves as a participating member of the facility's utilization review committee.

Supervises a staff of clerical/technical employees.

Serves as a consultant on medical records administration to other state facilities.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of medical record keeping principles and practices, including standard nomenclature and classification.

Knowledge of medical and anatomical terminology and of disease etiology required for the proper classification, maintenance, and custody of medical and program services case records.

Knowledge of the medicolegal requirements relating to the maintenance and release of information from medical records.

Knowledge of standards set by the Joint Commission on Accreditation of HealthCare Organizations, Health Care Financing Administration, Accreditation Council on services for People with Developmental Disabilities, and the Federal and State Government for Medicare and Medical Assistance programs.

Knowledge of statistical principles and techniques as they apply to medical records work.

Ability to develop and implement policies and procedures that assure proper medical records completion and maintenance and compliance with accrediting/certifying agencies' requirements.

Ability to plan, assign, and supervise the specialized and routine clerical work of subordinates engaged in the classification and maintenance of medical records and to instruct new employees in routine and specialized clerical work.

Ability to perform complex work in analyzing, coding, indexing, and filing medical records.

Ability to establish and maintain effective working relationships with subordinates, physicians, other facility personnel and the public.

MINIMUM EXPERIENCE AND TRAINING: Registration as a Medical Records Administrator with the American Health Information Management Association;

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Two years of experience as a Medical Records Technician; and registration as a Medical Records Technician with the American Health Information Management Association;

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Four years of experience in the preparation, classification and abstracting of medical reports in a medical records department; and registration as a Medical Records Technician with the American Health Information Management Association.