Medical Records Nurse (LPN)

Description

Cavalier Healthcare of Trussville

Position: Medical Records Nurse (LPN/RN)
Department: Nursing
Reports To: Director of Nursing / Administrator
Employment Status: Full-Time

Position Summary

The Medical Records Nurse is responsible for maintaining accurate, complete, organized, and confidential resident medical records. This position ensures compliance with federal and state regulations, supports nursing documentation standards, and assists with survey readiness and quality assurance initiatives.

Essential Duties and Responsibilities

Medical Records Management

• Maintain accurate, complete, and organized medical records for all residents.
• Review resident medical records daily for missing or incomplete documentation.
• Ensure all medical records are properly scanned, uploaded, indexed, and filed in the electronic medical record system.
• Maintain admission, discharge, transfer, and deceased resident records.
• Ensure medical records are completed and closed following resident discharge.
• Maintain an organized filing and retrieval system for active and discharged resident records.
• Ensure resident records are readily accessible to authorized personnel.

Physician Orders and Clinical Documentation

• Review physician orders for accuracy, completeness, and required signatures.
• Monitor outstanding physician orders and follow up with providers for timely completion.
• Track physician certifications and recertifications to ensure completion within required timeframes.
• Audit nursing documentation for completeness and compliance.
• Monitor completion of required nursing assessments and documentation.
• Identify missing physician progress notes, consultations, and other required clinical records.
• Communicate documentation deficiencies to the Director of Nursing and appropriate nursing staff.
• Follow up on outstanding documentation until deficiencies are resolved.

Chart Audits and Regulatory Compliance

• Conduct routine medical record audits on new admissions, current residents, and discharged residents.
• Complete weekly and monthly chart audits as directed by nursing leadership.
• Maintain audit logs identifying deficiencies, corrective actions, and completion dates.
• Assist with preparation for state surveys, complaint investigations, and regulatory inspections.
• Ensure medical records comply with applicable CMS, Alabama Department of Public Health, and HIPAA requirements.
• Monitor documentation trends and report recurring concerns to nursing leadership.
• Assist with implementing corrective action plans related to medical record deficiencies.
• Participate in Quality Assurance and Performance Improvement (QAPI) activities as assigned.

Admissions, Transfers, and Discharges

• Review new admission records to ensure required documentation is received and properly filed.
• Verify admission documentation is complete and notify appropriate staff of deficiencies.
• Ensure hospital discharge summaries and transfer documentation are available in resident records.
• Review discharge records for completion of required documentation.
• Coordinate with Admissions, Social Services, Nursing, and MDS departments to resolve documentation concerns.
• Maintain accurate records of resident admissions, transfers, discharges, and deaths.

Medical Record Requests and Confidentiality

• Process authorized requests for medical records in accordance with facility policy and applicable laws.
• Coordinate requests from hospitals, physicians, residents, legal representatives, and regulatory agencies.
• Maintain accurate logs of medical record requests and releases.
• Ensure proper authorization is obtained before releasing protected health information.
• Maintain strict confidentiality of resident medical information.
• Report suspected privacy violations or unauthorized access to resident records immediately.

Electronic Medical Records (PCC)

• Utilize PointClickCare (PCC) to monitor and maintain resident medical records.
• Review electronic charts for missing signatures, incomplete orders, and documentation deficiencies.
• Monitor outstanding physician certifications and recertifications.
• Assist nursing staff with locating and correcting documentation deficiencies.
• Ensure scanned documents are uploaded to the appropriate resident chart and record category.
• Report electronic documentation issues to nursing leadership or appropriate technical support personnel.

Communication and Department Support

• Communicate daily with the Director of Nursing regarding outstanding documentation concerns.
• Provide regular updates on chart audit findings and outstanding physician signatures.
• Collaborate with the MDS Coordinator, Unit Managers, Staff Development Coordinator, and other department leaders.
• Attend nursing department meetings and required in-service training.
• Assist with staff education related to medical record documentation requirements.
• Maintain professional communication with physicians, nurse practitioners, staff, residents, and families.
• Complete additional nursing administrative duties as assigned by the Director of Nursing or Administrator.

Requirements

PHYSICAL REQUIREMENTS:

• Hold/handle
• Lift
• Carry
• Reach – at and below shoulder height
• Push/pull
• Grasp and handle – pens, paperwork and small equipment
• Sit, stand and walk
• Twist, bend, stoop, kneel, and squat
• Fine hand motor coordination
• Ability to read and write legibly
• Ability to comprehend and follow instructions

COGNITIVE AND SENSORY REQUIREMENTS:

Talking: Communicating with residents, families, visitors and staff

Hearing: To communicate effectively on the telephone, Taking instructions from the Administrator, To respond appropriately to disaster instructions and pages

Sight: For performing job effectively and correctly

Smell: For accurate detection and maintenance of facility odors

LICENSURE REQUIREMENTS:

Must be a Licensed Practical Nurse (L.P.N.) currently licensed and in good standing with the Board of Nursing in the State of Alabama

SUMMARY OF OCCUPATIONAL EXPOSURE:

Tasks and procedures performed by the employee involve risks classified by C.D.C. as 

Category III.  (No contact with blood or other bodily fluids to which universal precautions apply, if regular duties are performed.)

OTHER CONSIDERATIONS AND REQUIREMENTS:

Must be able to tolerate a high pace as typical for a nursing facility.  Must be able to take and give instructions well and enjoy working with the elderly.  Although employee is required to sit for prolonged periods of time, he/she must also be able to tolerate prolonged standing and walking.