Summary

JOB SUMMARY:

Reporting to the Manager, Coordinator and/or designate, performs quantitative analysis on patient records by checking for completeness of the record. Maintains the record completion system in accordance with departmental policies, procedures and standards. Administers the physician suspension process regarding non-compliance regarding record completion.

QUALIFICATIONS:

Education

Grade 12, plus two years recent, related experience or an equivalent combination of education, training, and experience.

Skills and Abilities

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.

Ability to keyboard at 40 wpm.

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 and files onto patient records.

Maintains record completion systems by performing duties such as printing and distributing weekly physician notices of incomplete records and printing and distribution of 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.





Maintains records control by ensuring that all records are signed out in the tracking program according to established policy and procedures.

Answers inquiries related to the release of patient information for continuity of care by performing duties such as receiving request and releasing in accordance with established procedures. Refers problems or other inquiries as appropriate to Manager/Coordinator or designate.

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 merges duplicate numbers as required.

Participates in the quality assurance monitoring and audit functions by assisting the Manager/Coordinator/Supervisor by performing duties such as conducting actual reviews of incomplete records, counting records and maintaining workload statistics.

Follows up on missing records by performing detailed searches within the department and on the nursing units.

Processes records as requested by performing Records Management duties such as chart assembly, chart scanning, indexing, report filing and notification to physicians. Files reports into the patient records as assigned.

Files and retrieves records as required.

Orients current staff and students to the work of the section by demonstrating work methods, and answering questions.

Prepares requisitions for office supplies as needed. Maintains inventory of equipment and supplies as required.

Performs other related duties as assigned.

Job Accuracy Posting Flag

The hours of work, including start and stop times, days off, work area and work site may be subject to change consistent with operations requirements and applicable provisions of the Collective Agreement and statutes. Testing may be required. *A criminal record check may be required

📌 Clerk IV, Record Completion (Surrey)
🏢 Providence Health Care
📍 Surrey