Health Information career pathway

Maintain paperwork for transfer or referrals; Ensure orders and records are received upon resident return. File or scan all incoming clerical information in the in-house or electronic records. Track and schedule routine labs and x-rays and transcribe vitals, input/output information, etc. into the appropriate document system.

Provide and maintain information when requested by physician or facility staff engaged in research or study projects. Retrieve charts for examination by physician or other authorized persons.Maintain file of physician visits and notify appropriate physician when resident visit is due and summarize patterns of audit problems and present findings to the Director of Nursing.

Oversee the Care Plan process and serve in a support capacity to the Registered Nurse Assessment Coordinator(s).

Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation of CATs and CAAs. Develop, implement, and maintain an ongoing quality assurance program for the resident assessment/care plans. Conduct or coordinate the interviewing of each resident for the resident’s assessment. Work with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident and ensure that appropriate health professionals are involved in the assessment and the team is aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the penalties for false certification.