Job Descriptions For Winning Wheels

Medical Records


The primary purpose of your job position is to maintain medical records and resident care plans in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained.


As Medical Records/Care Plan Coordinator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.


Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position.


1 = Tasks may involve exposure to blood/body fluids.
2 = Tasks do not involve contact with blood/body fluids but could result in performing a Category 1 task.
3 = Tasks do not involve any risk of exposure to blood/body fluids.


  • Receive and follow work schedules/instructions from your supervisor and as outlined in our established policies and procedures. 3
  • Assume responsibility for the completion and accuracy of each resident care plan. 3
  • Prepare flow sheets, assignment sheets, and/or care cards/care sheets for nursing personnel. 3
  • Assist in developing methods for coordinating resident services to ensure the continuity of the residents� total regimen of care. 3
  • Ensure that reference material (i.e., PDR�s, Federal and State Regulations, etc.) maintained at the nurses� station is current.
  • Recommend written material that will assist the Nursing Services Department in meeting the day-to-day needs of the resident. 3
  • Assist in organizing, planning and directing the medical records section in accordance with established policies and procedures. 3
  • Thin resident charts as needed. 3
  • Maintain minutes of meetings/files as necessary. 3
  • Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility, to assure that medical records can be properly maintained. 3
  • Collect, assemble, check and file resident charts as required. 3
  • Ensure incomplete records/charts are returned to nursing service or the appropriate department for correction. 3
  • Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing. 3
  • Follow established policies and procedures for the medical records section. 3
  • Maintain a record of authorized information taken from charts/records, i.e., type of information, name of recipient, date, department, etc. 3
  • Collect charts, assemble them in proper order, and inspect them for completion. 3
  • Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed. 3
  • Assist in admission, transfer and discharge procedures as necessary. 3
  • Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary. 3
  • Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.). 3
  • Assure that medical records taken from the department are signed out and signed in upon return to the department. 3
  • File active and inactive records in accordance with established policies. 3
  • Index medical records as directed. 3
  • Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility. 3


Work with the interdisciplinary team to ensure that each care plan is completed in a timely manner and resident services are being provided. 3 Answer telephone inquiries concerning care plan functions. Prepare written correspondence on a quarterly (or as needed) basis to each resident�s family to invite them to care plan meetings. Also follow up with same after a resident�s care plan as needed. 3 Coordinate and organize resident and family care plan meetings. 3 Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on his/her needs. 3 Review interdisciplinary progress notes to determine if the care plan is being followed. 3


Attend various committee meetings of the facility (i.e. Quality Assurance) as required. Implement recommendations from established committees as necessary. 3


Report problem areas to the Administrator. 3 Develop and maintain a good working rapport with other departments within the facility. 3 Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment. 3


Assist in the orientation program for all personnel in accordance with Pleasant View policies and procedures. 3 Attend and participate in continuing education programs. 3


  • Perform secretarial duties for committees of the facility as directed. 3
  • Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. 3
  • Attend and participate in inservice educational classes and on-the-job training programs as scheduled. 3
  • Attend and participate in workshops, seminars, etc. as approved. 3
  • Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately. 3
  • Report equipment malfunctions or breakdowns to your supervisor as soon as possible. 3
  • Ensure supplies have been replenished in your work as necessary. 3
  • Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of work day, etc. 3


Maintain confidentiality of all pertinent resident care information to assure resident rights are protected. 3 Assure that residents' rights to fair and equitable treatment, self-determination, individuality, privacy, freedom from abuse/neglect, property and civil rights, including the right to present complaints, are followed. 3


  • Works in office areas as well as throughout the facility.
  • Sits, stands, bends, lifts and moves intermittently during working hours.
  • Is subject to frequent interruptions.
  • Works beyond normal working hours as necessary.
  • May be subjected to infectious diseases, substances, contaminated articles, etc., including the potential exposure to the AIDS and Hepatitis B viruses.
  • Communicates with nursing personnel and other department personnel.
  • Is subject to hostile and emotionally upset residents, family members, personnel, and visitors, etc.
  • Is involved with residents, family members, personnel, visitors, government agencies and personnel, etc., under all conditions and circumstances.


Must possess, as a minimum, a high school diploma or equivalent.


Must be able to type a minimum of 45 words per minutes, and have a working knowledge of medical terminology. On-the-job training provided in medical record procedures. Experience with computers and related software (Windows �98, Medical Records) preferred.



  • Be able to read, write, speak, and understand the English language;
  • Possess the ability to make independent decisions when circumstances warrant such action;
  • Possess the ability to deal tactfully with personnel, residents, visitors, and the generalpublic;
  • Be knowledgeable of medical terminology;
  • Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care;
  • Have the ability to work harmoniously with other personnel;
  • Possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices;
  • Be able to follow written and oral instructions;
  • Be knowledgeable in computer software applications/data entry.

PHYSICAL AND SENSORY REQUIREMENTS (With or Without the Aid of Mechanical Devices)

Must be able to:

  • Move intermittently throughout the workday;
  • Speak and write the English language in an understandable manner;
  • Cope with the mental and emotional stress of the position;
  • See and hear or use prosthetics that will enable these senses to function adequately to assure that the requirements of this position can be fully met;
  • Function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel;
  • Be in good general health and demonstrate emotional stability;
  • Assist in the evacuation of residents.

Tasks assigned to this position do not involve exposure.