Clerical Spec-HIM in Sanford, NC at Central Carolina Hospital

Date Posted: 7/24/2019

Job Snapshot

Job Description

Central Carolina Hospital


Provides the hospital with the support and management of information as it pertains to all facets of the Health Information Management Department and related medical record functions ensuring compliance with The Joint Commission, and federal and state regulatory guidelines, and the Medical Staff Bylaws.

Essential Functions:
  1. Retrieves discharged patient records from all nursing units and the Emergency Department, and verifies that all records are accounted for.
  2. Preps each chart by ensuring correct patient identification is on each document (front and back)
  3. Groups like documents in the appropriate order and further groups in date order.
  4.  Reviews each page of the record for poor original documents and items that cannot be scanned.
  5. Removes staples, paper clips, and post-its; ensures rhythm strips and other small documents are taped to 8 1/2 x 11 paper for scanning.
  6. Scans all records into the Horizon Patient Folder (HPF) in a timely manner to avoid delay in further processing. 
  7. Ensures scanner is kept clean and in peak performing condition to enhance image quality. 
  8. Indexes all documents to the appropriate patient folder with the appropriate document name.
  9. Reviews each discharged patient record for incomplete or missing items.
  10.  Identifies the responsible practitioner for each item and links the deficiencies to the appropriate physician for completion.
  11. Monitors physician decline que daily and reassigns deficiencies when appropriate.
  12.  Supports the Horizon Patient Folder as the legal medical record by validating the accuracy and completeness of each document scanned and indexed into the system.
  13. Utilizes the HPF system to fax/copy medical record documents in support of requests from physicians, physician office staff, other medical treatment facilities, hospital staff, and patients.
  14. Retrieves transcribed reports from transcription printer, charts in appropriate medical record, and distributes copies as appropriate.
  15. Maintains patient confidentiality at all times.

Job Requirements


High school diploma or equivalent is required

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran


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