Carleton-Willard Village is a premier Continuing Care Retirement Community located in Bedford, MA. Services include supportive care, skilled nursing, rehabilitation, and memory care all in a village-type setting. Our 72 acre sanctuary of pristine woods, meadows, walking paths and gardens is just north of Boston.
FT, Mon-Fri:
8:30 am -3:30 pm
Position Summary:
Accounts, assembles, maintains and audits all discharged medical records for accuracy, completeness, dates and appropriate individual’s signatures.
Duties and Responsibilities:
- Assemble discharged resident records in a uniformly organized manner for ease of reference to the resident’s information after discharge.
- Identify records with name, alpha tabs, medical record number and discharge/expiration date.
- Fill out Deficiency sheets as needed and route unfinished records to appropriate personnel for completion.
- Send incomplete physician records to the clinic on the day that the physician is scheduled to be there.
- Attach the checklist to the front of the record with colored removable tabs on deficient pages so that these items can be easily located.
- Follow up regularly on incomplete records to obtain prompt return.
- File completed records.
- File loose, overflow and late reports from nursing units, rehab department, hospitals and doctor’s office into the closed charts.
- Keep boarder charts and discharge charts separate.
- Account for all discharged medical record volumes.
- Remove discharged records annually after being stored for three years on CWV premises and send to an off-site storage. (Iron Mountain)
- Maintain “Medical Record Audit Tools” documents for QI purposes.
- Copy charts as requested by the Administrator and/or DON. (Court orders, litigations, Medicare appeals, insurance claims, family requests and cancer research)
- Keep all discharge charts (name, record number, date of discharge and volume #), updated on the computer.
- Check communication list daily. This information is then recorded on a customized form to keep track of unclosed charts. It keeps track of the name of the discharged resident, the floor he/she was on, the D/C date, the date that the chart was received from that particular unit, the date the chart was closed, and the location of the filed chart.
- Keep all other tracking forms updated.
1. Active Resident List
2. Discharged/Deceased List
3. Boarder Residents List
- Retrieve requested charts for various departments.
- Attend various in-services and staff meetings to keep informed of any issues and/or changes at CWV.
- Label narcotic and nursing logbooks before placing in archives.
- Perform all other job-related tasks as required.
- Provide Nursing payroll back-up.
Qualifications:
- Comprehensive knowledge of Carleton-Willard Village policies, procedures and philosophy of operation.
- High School Diploma or equivalent.
Carleton-Willard Village is committed to providing equal opportunity for employment and advancement to all team members and potential team members. Carleton-Willard Village does not discriminate in employment on the basis of race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/ or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations.