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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00149398 |
Description Activated On: 1/29/2025 3:00:10 PM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. The employee in this position is responsible for assisting in the preparation and maintenance of the computerized and manually generated patient tracking system; the completion of the inpatient/discharged/deceased medical records; assisting in the coding of emotional/psychiatric and/or medical/physical diagnoses; preparation and maintenance of various files, indices, and registers; the coordination and completion of requests for statistical and/or patient information; and maintenance and retrieval of the inpatient/discharged/deceased medical records; and is accountable for the completeness, accuracy, safekeeping, and availability of the medical records. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. Maintains security and confidentiality of the medical record by adhering to the Danville State Hospital confidentiality policy and hospital accreditation/certification agency standards in order to safeguard the medical records against fire, loss, tampering with, or use by unauthorized persons. Analyzes for completeness the medical records both paper and electronic for all inpatient/discharged/deceased patients following acceptable procedures and/or guidelines in order to ensure the completion and accuracy of medical records. Sends deficiency notices to appropriate persons/services for record completion. Maintains a record of such transactions as well as the chart review procedure to be used for Quality and Appropriateness Peer reviews. Codes emotional/psychiatric and/or medical/physical diagnoses using a standard nomenclature and acceptable classification systems in order to provide a means of gathering statistics on patient morbidity/mortality as well as provide a basis for a uniform patient “billing” system. Initiates a medical record on all patient admissions by entering all patient information into the electronic health record and making two addressograph cards; and distributing the cards to the proper persons in order to use for stamping paper records that need to be scanned into the electronic health record. Monitors psychiatric assessments/reassessments and annual physical and neurological examinations by maintaining and checking the database in order to provide timeliness documentation by the attending physicians. Responsible to monitor discharge summary and medical discharge notes. Reviews medical records by performing quantitative reviews against established medical record criteria checklist in order to insure that the medical records comply with policies/standards established by Danville State Hospital, the medical staff, and hospital accrediting agencies standards, and to ensure that the deficiencies are corrected accordingly. Reviews medical records by performing qualitative reviews against established medical record policies/procedures and standards in order to ensure that medical records are analyzed, purged, and adequately supplied with an ample supply of necessary forms in order for other services to perform their functions. Follows policies/procedures for receiving and completion of requests for patient information. Requests may be received via telephone, in person, or in writing. Tasks may include coordination with other personnel/departments; retrieval of the medical record both paper and electronic; photocopying pertinent material; logging of the receipt of the request, date and amount of material sent and to whom, including amount due. Releases patient information in accordance with the Danville State Hospital confidentiality policy in order to maintain good public relations with all inquiries. Completes release of information requests for records and maintains the disclosure management system. Stamps all medical record forms to be scanned into the electronic health record by utilizing the patient addressograph plate and the addressograph stamper in order to provide accuracy of patient data and to identify the patient. Performs other related duties as assigned within one’s capability and training under the direct and close supervision of the immediate supervisor, or designee, in order to assist with maintaining hospital services. ADA ESSENTIAL JOB FUNCTIONS: Maintains security and confidentiality in regard to medical record information. Operates and maintains the following pieces of equipment in order to perform day-to-day responsibilities: computer, copy machine, shredder, stamping and embosser machines. Maintains, assembles, reviews, and ensures completion of the medical records according to hospital guidelines. Codes emotional/psychiatric and medical/physical diagnoses using standard nomenclature and acceptable classification systems. Prepares and maintains card files and statistical files relating to medical records. Follows policies/procedures for receiving and completing requests for patient information. Effectively communicates with other offices/staff/agencies to convey or obtain information. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Decisions made include ICD-10-CM coding choices, maintenance of the medical record regarding purging issues, release of information, and telephone inquiries. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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