Highlands Behavioral Health System is an 86 bed freestanding behavioral health hospital offering psychiatric care for adults and adolescents. Centrally located in Littleton, the facility is easily accessible to families throughout the Front Range and just minutes from surrounding communities.
The HIM Technician, under general supervision of HIM Manager performs clerical tasks related to preparation of medical record files, assembly & analysis of the inpatient medical record, identification of medical record deficiencies as well as data entry of the medical record deficiency into the computer software. HIM Technician assists physicians and staff with chart location and medical record completion as defined by Joint Commission, state, federal medical record requirements, corporate, and hospital policies.
· Using the ADT Report retrieves discharged medical record from the inpatient units the day after discharge with the exception of weekends and holidays.
· Assembly of Inpatient Medical Records
· Analysis of Inpatient Medical Records.
· Completes the photocopying, faxing, and mailing of designated medical record reports to community providers.
· Pulls and prepares medical records for hospital and medical staff requests. Delivers medical records to physicians and other staff as requested. Responsible for accurately tracking the location of a medical record and subsequent return of the medical record by the end of the HIM Technician's shift.
· When pulling records for chart completion, the HIM Technician, pulls charts using the most current Medical Record Deficiency by Provider printout. The oldest aged charts are prioritized for completion based on the true age of the deficiency.
· When a medical staff member completes a medical record, the HIM Technician is responsible for the accurate removal of the deficiency with a 98% accuracy standard. HIM Technician is responsible for verifying the removal of the deficiency against the printing of the medical staff member's deficiency list.
· Works directly with physicians and physicians' offices to resolve deficiencies.
· Using the computer entry software, performs weekly reanalysis of the discharged medical record.
· Monitors physician completion of medical records to assure completion of medical record within 30 days of discharge. Advises HIM Manager weekly of deficiencies that exceed 30 days aged.
· On a daily basis processes physician dictation. HIM Technician crosschecks dictation against the Transcription Log. HIM Technician is responsible for filing unsigned dictation in individual medical staff signature folders in terminal digit order.
· Assures and verifies that all dictation has been signed before placing the original in the medical record.
· Schedules and completes monthly audit of chart locator file cards. Quarterly, completes an audit of incomplete medical records.
· Responds to authorized requests for release of information according to state and federal regulations as well as hospital policies.
· As a thorough working knowledge of HIPAA Privacy policies and procedures as well as 27-10 and can assist patients and staff relative to HIM Department responsibilities regarding authorizations, patient access, request for amendments, accounting of disclosures, and minimum necessary standards.
· Identifies inactive medical records for removal from the active files according to the criteria established by HIM Manager. Coordinates archiving of the inactive medical record twice a year.
· On an ongoing basis assures that loose filing is current and filed accurately in the proper medical record in the established chart order with an accuracy rate of 95%.
· For RHIT Technicians, coding with 95% accuracy and meeting the standard of no less than 3-4 charts per hour.
· Provides back up coverage ,support for HIM staff, and other duties as requested.