Medical Record Job Description

To provide a professional, efficient and effective Medical Records service to the Trust and its associated hospitals.

The postholder will provide records to and receive them. This involves preparing bags or boxes of records for delivery to these sites and processing bags or boxes received from these sites, including forwarding items of post.

The postholder will communicate the location of casenotes electronically by updating the iCS system (PAS) and on paper by filling out tracer cards.

Level of Clinical Responsibility-Medical Record Job Description
Using IT generated picking lists, the Postholder will extract casenotes from the Medical Records Library and check that these are in an appropriate condition to ensure that information necessary for clinical care is available to front line clinical staff whenever required. S/he will also renew casenote covers, which have become worn, damaged, or unusable, and divide casenotes into sub-volumes to support frontline clinical staff.

Leadership and Staff Management Responsibility

The Postholder will provide training and guidance on systems and procedures to new or less experienced departmental staff as required.

Financial Responsibility-Medical Record Job Description
The Postholder will observe a personal duty of care in relation to the use of equipment and all resources used in the course of work.

Service Development and Improvement

The Postholder will comply with policies and procedures impacting on the Medical Records Department and clinical departments throughout the trust. S/he will be required to encourage staff groups from all clinical specialties to comply withpolicies and procedures relating to all aspects of medical records management including handling, casenote tracking, filing (including loose filing) and merging. S/he will also extract casenotes from the Library to support clinical audits and clinical research throughout the Trust.

On a weekly basis the Postholder will provides Key Performance Indicators data to the Medical Records Supervisor as requested for collation to audit the Medical Records Department`s performance and to identify opportunities to improve the service provided.

S/he will identify and propose (eg at monthly staff meetings) improvements to policies and procedures operating within the Medical Records Department and/or impacting on `customer` clinical departments. [cont below]

Responsibility for dealing with difficult situations-Medical Record Job Description

The Postholder will be required to use tact and sensitivity in handling complaints and pressure from service users relating to service failures or non-availability of medical records. An important part of the role is to ensure that deadlines for provision of notes for frontline clinical staff are always met. This frequently involves prioritizing between different tasks, and responding to ad hoc enquiries, requests for casenotes, etc, and other interruptions, including those involving changing tasks, as appropriate. Non-routine enquiries may be referred to the Medical Records Supervisor.

The Postholder therefore works within Standard Operating Procedures but uses initiative to resolve problems and respond to enquiries and requests, especially in the absence of the Medical Records Supervisor There is a frequent requirement to analyze information (e.g. from iCS) to identify correct patient casenotes when data provided is ambiguous or incorrect, and/or in order to locate missing casenotes within and outsidethe library. In addition, the postholder will track all casenotes being issued from the library on iCS. This is a frequent task and entails prolonged periods of concentration.

The Postholder will carry out filing of casenotes in the correct location within the library and also of loose paperwork in appropriate sections of the casenotes, ensuring the correct casenote filing protocols are followed at all times. S/he will undertake weeding and/or culling of casenotes as and when necessary. All of the above are frequent tasks and entail prolonged periods of concentration. There is regular exposure to clinical photographs, which may be distressing to some staff.

Physical Working Conditions and Environment

There is a frequent requirement to exert moderate levels of physical effort for prolonged periods with intense physical effort for several short periods during working hours, including pulling casenotes from and refiling them on racks including at above shoulder height and at ground level and within restricted space), lifting and carrying casenotes within the Medical Records Department. Lifting and manual handling is therefore an essential and ongoing aspect of the role. In addition, ensuring thatthe library is kept in an orderly state at all times is a requirement of the role involving the physical tidying (but not the cleaning) of the area.

There is regular exposure to dust from paper records.

The use of keyboards for short periods at a time is a frequent requirement of the role.