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Maintain a manual of approved
medical record policies, procedures, abbreviations and forms that govern
the content, documentation and formats for the medical records of the
hospital's active and discharged clients; coordinate the process for the
review and approval of additions/changes to the manual, which must be
approved by the Medical Staff Executive Committee.
Disseminate
information and educate appropriate hospital staff about the hospital's
policies, procedures and expectations regarding medical records.
Store, safeguard
and provide access to the medical records of discharged clients in
accordance with applicable laws, rules, policies, procedures and JCAHO
standards.
Conduct ongoing
reviews/audits of the hospital's medical records, including reviews of the
records of all discharged clients, reviews of random samples of active
clients, and special/focused audits as requested/indicated; the purpose of
the reviews/audits is to identify opportunities for improvement in
compliance with established medical record procedures/standards and in
documentation in the records.
Code all client
diagnoses and medical procedures for billing and for the client
information system (Avatar Hospital Information System) and
statistical purposes.
Provide medical
transcription services to all hospital physicians and to other
professional staff as needed.
Provide support
for the integrity of the information in Avatar (hospital information system),
including
verification of the daily census with each client unit, checking
to see that all information on each admission
is entered, and compiling
reports of analyses of Avatar data entry errors for performance improvement.
Upon a client's
discharge from the hospital, process documents to provide relevant client
demographic and medical information to the designated aftercare agencies
to facilitate follow-up and continuity of the client's care; also, prepare
the necessary documents when clients are transferred to another facility.
Provide Cancer Registry Reporting to the
Georgia Comprehensive Cancer Registry in accordance with the Notifiable
Disease Law, Official Code of Georgia (OCGA) Annotated 31-12-2.
Comply
with applicable laws, rules, policies, procedures and JCAHO standards
governing the confidentiality, security and integrity of the medical
record and promote compliance hospital-wide.
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