ASC Business Office Staff Tasklists: Medical Records Specialist
These tips, part of an ongoing series that identifies ASC business office staff positions and provides suggested responsibilities for auditing purposes and evaluating employee progress, focus on the Medicare Records Specialist.
Medical Records Specialist
1. Understands:
Compliance plan requirements for medical records.
Time constraints of medical record completion per facility policy and procedure.
Components required for medical record (e.g., operative report, history and physical, laboratory reports).
Medical records confidentiality and laws governing access.
2. Copies and mails or faxes transcribed procedure reports to providers unless this service is provided by transcription service.
3. Copies and mails or faxes response to requests from approved outside sources for medical records. This request must be accompanied by appropriate release of information form signed by patient and approval by administrator.
4. Utilizes medical records checklist, checks for presence of all necessary forms and reports and puts medical record in order per facility policy and procedures.
5. Flags required signatures and/or initials.
6. Obtains all necessary signatures (e.g. provider, anesthesiologist, anesthetist (CRNA), nurse).
7. When final signatures are obtained, performs final check of medical record and completes medical record checklist and signs.
8. If medical record is paper, files in locked medical record filing cabinet/room upon completion.
9. If digital, stores in appropriate area of software program with password protection.
The final set of tips in this series will focus on the Business Office Coordinator. Access the other tips in this series on ASC business office staff tasklists.
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