Jurisdiction:
Jurisdictional Class: Competitive
Adopted: 9/30/2010
MEDICAL
RECORDS ADMINISTRATOR
DISTINGUISHING FEATURES OF THE CLASS:
The work involves responsibility for managing,
organizing and supervising a facility’s medical record program and evaluating
and modifying medical record systems to meet particular needs. Duties include developing and implementing a
system for acquiring, analyzing, coding, storing and retrieving detailed
patient medical records in accordance with facility goals and standards of
accrediting and regulatory agencies.
Basic medical records under control of the Medical Records Administrator
consist of individual patient files containing such information as medical history,
admission, diagnosis, prognosis, treatment, progress, transfer and
discharge. Positions in this class are
characterized by the performance of a full range of professional medical
records activities requiring the application of the theories and techniques of
medical records library science in the development, maintenance, analysis and
use of diagnostic and therapeutic medical records. The incumbent provides advice and
consultation to department management and staff members on medical record
problems and procedures. Supervision is
received from the department’s Administrator and allows the incumbent wide
latitude in the control and management of the medical record system. Does related work as required.
TYPICAL WORK ACTIVITIES: (Illustrative only)
Plans and develops record retention, preservation and
retrieval systems in accordance with facility goals and standards of accrediting
and regulatory agencies;
Determines, in conjunction
with the departments management and professional staff,
appropriate
methodology and standard classification and indexing best suited to
the
facility’s needs. Develops, promulgates,
and revises medical record goals, procedures and guidelines as needed;
Analyzes the utilization of
medical records and designs systems to improve their
Usefulness;
Provides training to
facility staff on proper work procedures and techniques, answers
questions
and assists in solving problems;
Reviews and analyzes medical
records to ensure that the records meet the
requirements
of accredited agencies, meet legal requirements, and meet needs
for
future treatment of the patient;
Determines that the
necessary components such as progress notes, nurses’ notes,
laboratory
reports and treatment records are present and complete; that the
terminology
used by the clinicians is in keeping with accepted nomenclature; that
he
contents of the record appear to be accurate and internally consistent and
filed
in an established sequence; and that all omissions are noted;
Supervises the collection
and completion of data from the records for regular and
special statistical reports and studies,
including official reports for State and
Federal
agencies;
Provides advice,
consultation and assistance on medical record matters to department
management
and staff by serving as a member of the Medical Records
Committee
and Utilization Review Committee, advising clinical supervision on
medical
record policy and procedures and instructing treatment staff in proper
methods
of entering observations and progress notes in medical records.
FULL PERFORMANCE KNOWLEDGES, SKILLS, ABILITIES AND
PERSONAL CHARACTERISTICS:
Good knowledge of the
principles, methods and practices of modern medical record
library
science and their application to mental health care;
Good knowledge of pertinent
Federal, State, Departments and accrediting agency, legal
and
policy requirements and regulations relating to the maintenance and release
of
medical records information;
Working knowledge of departmental
policies and procedures;
Working knowledge of the
mechanical and electronic techniques for processing medical
records
information;
Ability to establish and
maintain effective working relationships with clinical staff,
physicians
and other departmental staff;
Ability to establish and
maintain effective working relationships with outside agencies
such
as the Courts, Probation, Department of Social Services, etc.;
Ability to recognize
inconsistencies and omissions in medical records;
Ability to instruct department
staff in activities related to the maintenance of complete
and
accurate medical records;
Physical condition
commensurate with the demands of the position.
MINIMUM QUALIFICATIONS: Graduation from a regionally accredited college or university or one accredited by the New York State Board of Regents to grant degrees with a Bachelor’s degree or higher and two (2) years of full-time paid work experience in the maintenance, review, analysis and use of medical and/or legal records.