Record Completion and Quality Check Clerk
Providence Health Care
Within the context of a client and family centred model of care and, in accordance with the Mission, Vision and Values, and strategic directions of Providence Health Care, the person promotes a safe, respectful, and civil working environment for patients, residents, families, visitors and staff.
Reporting to the Manager, Records Management & Registration or designate, the Clerk IV, Records Completion & Quality Checks, performs quantitative analysis on patient records by checking for completeness of the record. Maintains record completion system in accordance with departmental policies, procedures and standards. Administers the physician suspension process in relation to non-compliance regarding record completion.
The position also checks, generates and reviews standard audit reports from electronic health record systems to ensure accuracy and completeness of chart documentation. Identifies discrepancies, corrects errors, follows up on missing documentation and/or notifies users of required corrections. Informs users and area Managers regarding instances of repeated errors and refers them to established records management standards and procedures. Performs random audits on scanned documents to assess scanning image quality and accuracy of indexing. Provides feedback to scanning clerks regarding existing standards and guidelines for document imaging. Maintains and updates user manuals as directed. Tracks instances and follows up with Medical Administration regarding ongoing issues with electronic signature compliance as per established procedures. Monitors HIM in-box for refused orders. Identifies reasons for refusal and completes Patient Safety Learning System (PSLS) form if required as per established procedures. Performs other qualitative and quantitative analysis on health records and general clerical duties as required.
Qualifications / Skills and Education
Grade 12, plus two years recent, related experience or an equivalent combination of education, training, and experience.
Skills and Abilities
Ability to keyboard at 40 wpm.
Ability to communicate effectively both verbally and in writing.
Ability to deal with others effectively.
Knowledge of medical terminology.
Physical ability to carry out the duties of the position.
Ability to organize work.
Ability to operate related equipment.
Duties and Responsibilities
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.
Maintains the record completion system by performing duties such as distributing weekly physician notices of incomplete records and 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.
Responds to physician queries regarding incomplete records.
Follows up with departments 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 identifies potential merges. Communicates with the Registration Data Quality group as necessary. Purges unit record numbers as required.
Follows up on missing records by performing detailed searches within the department and on the nursing units.
Runs system generated audit reports from applicable records management systems (e.g., ROI module), identifies errors from a report or within the clinical information systems, clarifies errors and/or obtains missing information, corrects and documents errors, and follows up with users and area Managers to notify them of repeated instances. Provides feedback/instruction on appropriate documentation requirements and directs users to applicable records management standards and procedures.
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.
Tracks instances and follows up with Medical Administration regarding issues with documentation, electronic signature compliance, and unsigned orders.
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.
Processes records as requested by performing Records Management duties such as chart prepping, chart scanning, indexing, report filing and notification to physicians. Files reports into the patient records as assigned.
Uses record tracking system to sign out and locate records as required. Files and retrieves records as required.
Participates in the quality assurance monitoring and audit functions by assisting the Manager by performing duties such as conducting actual reviews of incomplete records, counting records and maintaining workload statistics. Contributes suggestions for improvement to processes and audit mechanisms to Manager based on observed issues/errors. Attends and participates in quality related meetings to provide input and receive information as directed by Manager.
Orients new staff and students to the work of the section by demonstrating work methods, and answering questions.
Performs other related duties as assigned.
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.