Description
DMC Detroit Receiving Hospital,Michigan’s first Level I Trauma Center, helped pioneer the evolution of emergency medicine and currently has one of the busiest and most well-equipped emergency departments anywhere. The first and largest verified burn center in the state is at Receiving, and it is one of only 43 in the nation. Receiving also offers the state’s leading 24/7 hyperbaric oxygen program, Metro Detroit’s first certified primary stroke center, and the nationally recognized and accredited DMC Rosa Parks Geriatric Center of Excellence.
Summary Description
• Reconciles records against discharge census and takes appropriate and timely action to retrieve all discharged patient records
• Retrieves medical records from designated Patient Care areas, organizes, prepares and processes for document imaging
• Meets departmental quality and productivity standards for preparing, and scanning of patient records
• Other job duties as assigned based on skill level and need
o Movement of medical record documentation from incorrect to correct account numbers
o Paper to Image audits for scanned records
Performs birth and/or death records processing including, but not limited to, the following:
Birth Process:
• Processes birth certificates and affidavits of parentage
• Prepares and submits completed birth certificates to the Department of Health biweekly
• Assists walk-in customers in obtaining information concerning birth certificates and establishing paternity. Assists the state in updating records, providing information as to where the deceased infants were released.
Death Process:
• Ensures completion of Expiration documentation in medical record
• Ensures completion of Death Certificate
• Follow-up with physicians, Social Work, Security and Funeral Homes as needed
• Completes Morgue and Death Certificate Logs
• Works with Funeral Homes on body release
• Ensures all paper death-related forms are sent for scanning into the medical record
• In accordance with CMS and Joint Commission requirements, Medical Staff Policy and DMC Medical Rules and Regulations, performs the following functions related to medical record analysis and chart deficiency assignment/resolution:
o Analysis of in house patient medical records to determine if required History & Physicals and Operative Reports, as applicable, are complete, present and accounted for, with completed attestations and co-signatures as required
o Analysis of discharged patient medical records to determine if all required components are complete, present and accounted for, with completed attestations and co-signatures as required
o Accurate and timely assignment of deficiencies in Cerner Profile as appropriate
o Update status of accounts in 3M HDM, consistent with Profile deficiencies
o Contact physicians regarding delinquent records/missing documents
• May assist physicians with document completion process/access issues if needed
• Identifies and issues/patterns related to specific physicians, document types, etc., and escalates to leadership as appropriate
• Assists Supervision and Management with compilation of accurate and timely chart delinquency and suspension lists
• Must meet department productivity standards for chart analysis
• Assist with other job functions/projects as assigned by management; This may include but is not limited to the following:
o Assistance with Prep/Scanning Activities
o Movement of medical record documentation from incorrect FIN/Patient to correct FIN/Patient
o Paper to Image Audits for scanned records
o Periodic medical record reviews for Joint Commission and CMS requirements
Qualifications:
Minimum Qualifications
• High school diploma or GED required; AAS in Health Information Technology preferred.
• Two years of experience working in a Medical Records department or the equivalent experience completing medical records duties in another setting, or the completion of at least 30 credit hours of a Health Information Management Associate's degree program preferred.
• Basic Windows-based computer experience required; Excel and Word experience necessary.
• Understanding of HIPAA Privacy Rules.
Skills Required
Minimally:
• Analytical skills
• Organization and time management
• Windows-based computer experience, especially Excel and Word