Medical Records

Record Management:

• Organize and maintain electronic and paper health records according to established procedures.
• Ensure the accuracy, completeness, and integrity of patient information.

Data Entry and Coding:

• Enter patient information into the electronic health record (EHR) system.
• Assign appropriate codes to diagnoses, procedures, and other medical information using coding systems (e.g., ICD-10, CPT).

Confidentiality and Security:

• Implement and enforce policies and procedures to maintain the confidentiality and security of patient health information.
• Control access to medical records and ensure compliance with privacy regulations (e.g., HIPAA).

Release of Information:

• Process requests for release of medical information in accordance with legal and regulatory requirements.
• Verify the identity and authorization of individuals requesting medical records.

Quality Assurance:

• Perform regular audits of health records to ensure accuracy and compliance.
• Collaborate with healthcare providers to resolve discrepancies and enhance record quality.

Data Retrieval and Reporting:

• Retrieve patient information as requested by healthcare professionals for treatment and administrative purposes.
• Generate reports on healthcare data for internal and external use.