Summary

Within the context of a patient, client and family centred model of care and, in accordance with the Mission, Vision and Values, and strategic directions of Providence Health Care, promotes a safe, respectful, and civil working environment for patients, residents, families, visitors and staff.



Reporting to the Manager/Coordinator, or designate, the position performs duties related to the release of clinical information in accordance with policies, procedures, legislation and standards in the retrieval, severing, photocopying/scanning, electronic/paper distribution of health care documentation/reports. Responds to requests from internal/external sources for information regarding confidentiality and release of information policies and procedures; attends to legal requests for personal information and other related requirements. Performs quantitative analysis on patient records by checking for completeness of the record. Maintains the record completion system in accordance with departmental policies, procedures and standards. Administers the physician suspension process regarding non-compliance regarding record completion. Processes records, generates reports from applicable systems and performs related clerical functions as required.

Qualifications / Skills and Education

Education
Grade 12, successful completion of courses related to release of information and two (2) years of recent, related experience or an equivalent combination of education, training and experience.

Skills and Abilities

Ability to communicate effectively both verbally and in writing.

Knowledge of medical terminology.

Ability to deal with others effectively.

Ability to operate related equipment.

Ability to organize work.

Physical ability to carry out the duties of the position.

Ability to keyboard at 45 words per minute.

Duties and Responsibilities

Answers inquiries regarding requests for patient/client information by reviewing medical records, and determining information to release. Provides information to requestors such as WorkSafe BC, other hospitals and physician's offices by performing duties such as receiving requests; ensuring consent and authority to access the requested information is received and valid; following up with initiator of request where clarification or authorization is required; retrieving records and recording location in system, reviewing the records for accuracy, copying/compiling the requested information and forwarding information via appropriate method of delivery (e.g. photocopy, scan, mail), in accordance with established policies and procedures, and legislation such as the Freedom of Information and Protection of Privacy Act (FOIPPA). Records are severed as required and invoices are prepared as appropriate. Refers unusual requests to Manager/Coordinator or designate.



Maintains and updates release of information records using a computerized system; enters request information such as date of request, patient/client name, chart number, requester and date released. Provides statistical reports as required using computerized software as required.



Processes legal requests for personal information including certification of documents by performing duties such as numbering pages and completing and signing required standard form in accordance with established procedures. Represents organization to verify document authenticity as required.



Ensures Authorization to Release Information form is acquired prior to releasing information when such authorization is required in accordance with policies, procedures, legislation and standards. May respond to internal and external queries related to release of patient information.



Performs quantitative analysis on records by checking for completeness of the record (e.g., discharge summary, operation reports) and forwarding incomplete records to physician for completion in accordance with quantitative analysis procedures and within the organization's guidelines and standards. Enters deficiencies into computerized record completion module and files onto patient records.



Maintains record completion systems by performing duties such as printing and distributing weekly physician notices of incomplete records and printing and distribution of reports to Medical Administration, VP Medicine and Department Heads.



Administers the physician temporary suspension process regarding non-compliance around record completion in accordance with departmental procedures; generates pending suspension notices to physicians; notifies appropriate departments such as Registration of temporary suspension due to non-compliance.



Maintains records control by ensuring that all records are signed out in the tracking program according to established policy and procedures.



Responds to physician queries regarding incomplete records.



Follows up with areas such as Registration regarding problems with documentation such as questionable encounters, duplicate registrations and merges. Takes the appropriate steps to correct or resolve problems as required. Initiates edits and merges duplicate numbers as required.



Generates a variety of reports such as Activity, Census and Occupancy reports as requested from the computerized Admission, Discharge and Transfer System and distributes accordingly.



Processes records as requested by performing Records Management duties such as chart assembly, chart scanning, indexing, report filing and notification to physicians. Files reports into the patient records as assigned. Follows up on missing records by performing detailed searches within the department and on the nursing units.



Participates in the quality assurance monitoring and audit functions by assisting the Manager/Coordinator by performing duties such as conducting actual reviews of incomplete records, counting records and maintaining workload statistics. Provides input to Manager/Coordinator on procedure manuals and efficiency improvements for area. Attends team meetings and site committee meetings (e.g. Forms Committee) as required.



Orients new staff and students to the work of the section by demonstrating work methods, and answering questions.



Performs clerical and reception functions such as answering phones, filing, retrieving and delivering charts, preparing requisitions for office supplies as needed and maintaining inventory of equipment and supplies.



For Cerner Sites



Performs random audits as assigned on scanned documents within the clinical information systems for image quality and accurate indexing. Provides feedback to scanning clerks on data quality issues by providing instruction and/or referring them to standards and procedures for document imaging. Maintains user manuals by entering new updates as directed.



Monitors and reviews HIM In-box for refused orders. Identifies reasons for refusal and completes Patient Safety Learning System form as required in accordance with established procedures.



Performs other related duties as assigned.

Vaccination Flag

As per the current Public Health Orders (Long Term Care/Seniors Assisted Living Provincial Health Order and the Health Sector Order), as of October 26, 2021, all employees working for Providence Health Care must be fully vaccinated against COVID-19. Proof of vaccination status will be required.