Assistant Director for Medical Records

							DACUM Competency Profile for
Medical Records Assistant
DACUM PANEL MEMBERS
Gail Titchener, A.R.T.
Presbyterian Inter-Community Hospital
Whittier, CA
                                         Produced By
Alicia Loftin
Medical Records Tech
Greenhaven Country Place                                        Mt. San Antonio College
Sacramento, CA                                                         Region 7
Rosalie Majid, RRA, CMSC                                              Los Angeles Region
Director Hlth Info. Technology Program
Cypress College                                                    Southwestern College
Cypress, CA
                                                                        Region 10
Linda Meyers, A.R.T.
                                                                  San Diego/Imperial Region
Health Information Manager
Mad Rivers Comm. Hospital                                           Saddleback College
Arlata, CA
                                                                      Regions 8 & 9
Alesia Davis
Medical Records Tech                                            Orange County/Desert Region
Santa Barbara County Health
Santa Barbara, CA                                                      Mission College
Marissa Krentz                                                            Region 3
Clerk Typist II                                                            Bay Region
Salinas Valley Memorial Hospital
Salinas, CA                                                            Hartnell College
Tina Lerma                                                                Region 5
Medical Records Clerk                                                    Central Region
Presbyterian Inter-Community Hospital
Whittier, CA                                                            Butte College
DACUM FACILITATORS                                                      Regions 1 & 2
Colley Tettlebach
Project Director                                                Far North and North Regions
Hartnell College - RHORC
156 Homestead Avenue                                         City College of San Francisco
Salinas, CA 93901                                                      Region 4
Kathy Creed                                                           Interior Bay Region
Clinical Instructor
Mission College - RHORC                                       Santa Barbara City College
3000 Mission Blvd. MS#1
                                                                      Region 6
Santa Clara, CA 95054-1897
                                                                      South Coast Region


                                                                    September 17-18, 1998


                                         Developed and published under contract with the State of California Chancellor's
                                         Office, California Community Colleges, Ed Net Funding - 98-0228. Printed at
                                         Saddleback College, Regional Health Occupation Resource Center. Permission is
                                         hereby granted to reproduce this work, in whole or part, for classroom or curriculum
                                         use only.
DACUM Competency Profile for Medical Records Assistant
    Medical Records Assistant is a member of the health care team who participates in the maintenance and provision of health information
    to customers/clients contributing to continuity and quality of care.

            Duties                                                                             Tasks
    Process Medical Records       A-1 Validate medical record       A-2 Complete medical record      A-3 Assemble medical records     A-4 Analyze medical records
                                  number                            discharge procedure                                               for completeness
A

                                  A-5 Implement medical staff
                                  suspension procedure for
                                  delinquent records



    Maintain retrieval and        B-1 Retrieve records for          B-2 Deliver records to           B-3 Pull records for clinic      B-4 Maintain chart tracking
    storage systems               requesters                        requesters                       appointments                     systems
B

                                  B-5 Retrieve records from         B-6 Identify inactive records    B-7 Maintain inactive storage    B-8 Prepare records for optical
                                  archives                                                           log                              imaging




                                  B-9 Identify records for          B-10 Destroy records pursuant
                                  destruction                       to retention policy




    File Health Information       C-1 Process medical reports       C-2 Distribute medical reports   C-3 File reports in medical      C-4 File loose reports
                                                                                                     chart
C

                                  C-5 File medical records




    Coordinate Release Of         D-1 Evaluate information          D-2 Maintain "release of         D-3 Comply with release of       D-4 Respond to patient
    Information                   requests                          information" log                 information policy (e.g., HIV,   requests
D                                                                                                    MH, SA, HIV, Mental Health
                                                                                                     Substance Abuse)


                                  D-5 Respond to attorney           D-6 Respond to 3rd party         D-7 Respond to health care       D-8 Respond to subpoena
                                  request                           payer request                    provider request                 duces tecum




                                  D-9 Respond to patient access     D-10 Prepare billing statement
                                  request                           for production of records




    Manage Healthcare             E-1 Enter data into health care   E-2 Retrieve data from health    E-3 Abstract data from           E-4 Coordinate physician
    Database Information          databases                         care databases                   medical records                  order entry (long term care)
E

                                  E-5 Maintain adequate             E-6 Back up computer system
                                  computer hard drive space
    Process Birth Certificate   F-1 Gather necessary birth    F-2 Interview parents for birth   F-3 Complete birth certificate   F-4 Process paternity
                                information                   information                                                        opportunity program form
F

                                F-5 Maintain birth register   F-6 Complete fetal death
                                                              certificate




    Maintain Organizational     G-1 Participate in            G-2 Participate in workshops      G-3 Participate in performance   G-4 Order department supplies
    Responsibilities            institutionally required      and inservice training            improvement activities
G                               training



                                G-5 Design new forms for
                                long term care
EQUIPMENT, SUPPLIES AND                    Numerical filing
MATERIALS                                  Prioritize
 Bar code reader                           Problem solving
 Carts                                     Read medical information
 Chart jackets                             Terminal digit filing
 Computer                                  Title 22 OREGS
 Copier                                    Windows proficient
 Fax machine
 File cabinets                            WORKERS CHARACTERISTICS
 Flags (for deficiencies)                  Assertive
 Hole puncher                              Common sense
 Label printer                             Considerate
 Labels                                    Cooperative
 Micro fische reader                       Cost conscius
 Office supplies (e.g. pens, pencils,      Dependable
 sharpener, etc.)                          Detail oriented
 Postal scale                              Efficient
 Printer                                   Ethics
 Record storage files                      Flexible/adaptable
 Shredder                                  Good listener
 Stamps/stamp holder                       Honest
 Staples                                   Motivated
 Step stool                                Multi-skilled
 T.D./Alpha/Numeric sorter                 Organized
 Telephones                                Professional
 Typewriter                                Quick learner
                                           Respectful
FUTURE TRENDS AND CONCERNS                 Responsible
                                           Self-disciplined
 Coding of Dx and Procedures               Take initiative
 Computer based records                    Team player
 Confidentiality legislation               Tolerant
 Different roles in LTC and OP
 Different settings (e.g. LTC and OP)
 Emerging roles in health care
 HIPAA Health Insurance Portability and
 Accountability Act.
 Information technology
 Legal requirements
 Reimbursement patterns

KNOWLEDGE AND SKILLS
 10 key pad
 Alphabetic filing
 Body mechanics
 Case of references
 Communcation skilsl (verbal and
 written)
 Computer data entry
 Copier
 Customer service
 Fax machine
 Health information comp applications
 Interpersonal skills
 JCAHO STDS
 Keyboarding
 MCOP/Medicare conditions of
 participation
 medical terminology