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Medical Records Technician 216760
(Patient Care Component)

G S-675-05

I. INTRODUCTION:
This position is located at the Tohatchi Health Center in the Business Office Branch. The purpose of the position is to perform coding and data entry of medical information of Patient Care Component (P C C) encounter forms resulting from ambulatory, and community visits within the service unit.

II. MAJOR DUTIES:
40% - Coding: Encodes Encounter forms into the Service Unit R P M S data base using numerous entry mnemonics and editing options for:

a. Entry of clinical component parts of the P C C forms for information on diagnosis, procedures, treatments, examinations, measurement panels, lab/x-ray test orders and results, problem lists, treatment plans, immunizations and skin test results, patient education, past medical and surgical history and cause and place of injury reporting.
b. Entry of statistical information on clinic services, provider services, arrival times, location sites, and level of patient services.
c. Data entry of assigned I C D-98-C M codes involving the interaction of the P C C computer assisted system.
d. Retrieving information from the R P M S to assist in identifying and verifying information entered within the database.

Interprets and reviews documented medical information to accurately assign descriptive I C D-9-C M diagnostic and procedural codes which describes a patient’s encounter by:

a. Abstracting the necessary information to relate diagnoses with procedures.
b. Identifying secondary complications and co-morbid conditions.
c. Selecting and assigning proper diagnostic and therapeutic codes.
d. Sequencing codes in correct order to assure maximum allocation of Diagnostic Related Groups (D R G s) assignments, according to established coding principles and conventions.

35% - Data Review: Reviews the P C C database by conducting a verification process of information entered. As scheduled, runs the Visit Review Report (V R R) to identify and resolve missing mnemonic entries, classification/versus edits, coding/age edits, potential merge edits for all ambulatory clinics, inpatient hospitalizations, field visits, and conducts error resolution of data before export of information is made.

15% - Quality Control: Conducts quality control and improvement reviews by:

a. Tracking and identifying misadventures of inadequate documentation;
b. Communicating program software and hardware problems; and
c. Maintaining workload logs of forms processed.

5% - Records Maintenance/Confidentiality: Maintains confidentiality of patient records in accordance with the Privacy Act, J C A H O, I H S, and facility manuals.

5% - Performs other related duties as assigned.

Factors:

Factor 1 - Knowledge Required by the Position:
Knowledge of medical records principles, concept, and procedures as related to data entry functions and data flow in accordance with I H S health records regulations and service unit operations.

Knowledge of standardized medical record classification systems and references such as; International Classification of Diseases (I C D), Current Procedural Terminology (C P T), Diagnostic Related Groups (D R G s), Physician’s Desk Reference (P D R), medical dictionaries, textbooks to review and accurately assign diagnostic and procedural codes.

Knowledge of R P M S software programs, specifically; Patient Care Component, Patient Registration, Admission/Discharge/Transfer, and Maternal and Child Health for entering patient data.

Basic knowledge of medical terminology including suffixes and roots, accepted abbreviations, and pharmaceutical terms to accurately spell diagnosis and procedures.

Knowledge of basic anatomy and physiology of major anatomical systems to interpret diagnosis.

Knowledge of medical record forms, formats, filing system, and I H S standard codes to establish, analyze, locate, and maintain medical records.

Knowledge of legal regulations and requirements to assure confidentiality of patient information as it relates to the Privacy and Freedom of Information Act.

Knowledge and skill to operate microcomputer, video display terminal (V D T), a keyboard to interact and apply console commands.

Skill to collect and organize data for Quality Assurance reporting.

Factor 2 - Supervisory Controls:
The incumbent works under the supervision of the P C C Coordinator, who defines overall program goals and objectives. The supervisor provides direction and assistance for unusual circumstances which do not have precedent. The technician carries out recurring assignments and refers unanticipated or unfamiliar situations to the supervisor for final decision. The technician uses own initiative in choosing the best method for carrying out work according to procedures, instructions, and accepted practices of the medical records department. The supervisor reviews work for achieved results, accuracy, and timely completion for conformity to acceptable practice and standards.

Factor 3 - Guidelines:
Guidelines include a variety of technical instructions and manuals of regulatory requirements, that is, J C A H O standards, Service Unit policy, the Privacy Act, and organizational objectives set by the P C C Coordinator. The incumbent uses judgement to identify, interpret, select, and adapt the appropriate guidelines for operation. Incumbent uses knowledge and initiative to develop and implement action for problem resolution and program development for unusual or unresolved problems with referral to the supervisor for clarification and final approval to promote efficiency of the work unit.

Factor 4 - Complexity:
Work assignments are to solve routine problems of limited complexity. The duties involve related processes and methods for selecting and assigning codes, compiling, recording, and reviewing medical record data according to established procedures. The incumbent makes decisions about what needs to be done and recognizes the existence of differences among alternatives to correct technical errors using prescribed methods and performs other checks to assure the validity of information.

Factor 5 - Scope and Effect:
The work involves the performance of a variety of specialized medical record tasks and resolving of problems according to established standards for medical record analysis, coding and sequencing diagnosis and procedures, record establishment, processing, and maintenance, and quality assurance tracing. Performance of duty directly impacts the accuracy, relevance, timeliness, and reliability of medical record services and accreditation status for quality patient care, maximized reimbursements and research data.

Factor 6 - Personal Contacts:
Contacts are with medical and nursing staff, ancillary health care providers, medical record staff, business office, data processing, and employees within the immediate organization or work unit. Contacts are also with the patient population, family members, and the general public.

Factor 7 - Purpose of Contacts:
The purpose of contacts is to exchange factual information for medical services and clarification of data.

Factor 8 - Physical Demands:
The work is mostly sedentary with nominal walking, standing or carrying of light objects such as manuals, records or files. Good eye and hand coordination, including concentration is required.

Factor 9 - Work Environment:
The work is performed in a smoke free office setting. There is adequate light, heat and ventilation in the work area. The demands of the video display terminal and keyboards for long periods of time can cause eye, shoulder, and wrist strain if proper body mechanics and equipment are not used.

Other Significant Facts:
Incumbent is required to work on a rotational basis for shift, weekend and holiday coverage.