Health Information Management (HIM) Clerk II
The HIM Clerk II performs a variety of duties in connection with the operation of Health Information Management Department, relating to Release of patient information, filing of medical records, Monitoring, and maintaining chart delinquency process, Assembly and Analysis of medical records, Prepare, scan and/or quality review of the electronic record
SCANNING

• Performs recheck of medical record prior to scanning to ensure all signatures have been obtained as needed
• Performs recheck on all medical records prior to scanning to ensure required dictation has been obtained (to include documents in e-sign)
• Removes any electronic documents prior to scanning, according to policy and procedure
• Performs chart preparation for scanning, removing difficult items to scan (possibly requiring recopying of the page), removing staples and rubber bands
• Delete scanned image at the time error (i.e., wrong chart order, crooked scan, or cut off wording on the page) is discovered and starts process over
• Starts an e-form for quality check

RELEASE OF INFORMATION

• Ensures authorized release of medical record request by verifying valid authorization and following HIPAA and hospital policies
• Take charts to clinical areas as requested

CHART ASSEMBLY

• Check charts against the Daily Discharge Census List to ensure all charts are received
• Assemble charts in order as outlined in the HIM policy and procedure
• Review all documents to ensure patient identification is present and applicable to the current medical record being assembled
• Assures Advance Directives/Living Wills/Durable Power of Attorneys are scanned to the patient’s medical record, timely

ANALYSIS

• Analysis charts according to Policy and Procedures
• Verify through CPSI or DocuVoice the completion of dictated reports, prior to assigning deficiency
• Identify physician deficiency and assign appropriately on the deficiency slip
• Using the Medical Records Tracking system, accurately document location of charts in system, according to deficiency
• Utilizes the electronic health record and paper chart to ensure accurate analysis
• Prints documents requiring signatures, if physician does not e-sign, and places in correct order in the chart

FINAL ANALYSIS

• Confirms completion of deficiencies from physician’s incomplete chart room
• Reassigns deficiencies as appropriate until record is complete
• Utilizes the electronic health record and paper chart to ensure accurate analysis
• Verify through CPSI or DocuVoice the completion of dictated reports, prior to assigning deficiency
• Using the Medical Records Tracking system, accurately document location of charts in system, according to deficiency
• Prints documents requiring signatures, if physician does not e-sign, and places in correct order in the chart
• Perform a complete analysis on the chart, upon all deficiency completion, prior to sending chart to be scanned

QUALITY CHECK

• Performs quality review of scanned images to ensure proper alignment, readability, and all documents have been scanned
• Performs another page count to validate pages in scanned images
• Returns deficiencies discovered back to scanner with an attached form identifying said deficiencies

REQUIREMENTS

• Associates Degree in Health Information Technology, Applied Science or Business Administration required
• 6-12 months office work in medical field preferred