MEDICAL RECORDS SUPERVISOR 32101

2/16/90 A

This is the first class and supervisory level class in the Medical Records Management series for classes that are responsible for supervising the maintenance of medical records and medical information in a variety of agencies and institutions. Positions in this class plan, organize, and supervise the work of a small office services staff working in a medical records unit. The class is distinguished from the Medical Records Technician Senior class by its supervisory authority. It is distinguished from the Medical Records Manager class by the latter's responsibility for managing a larger, more complex medical records department.

Complexity of Work: Performs supervisory work of moderate difficulty involving the supervision of a single unit in a medium size facility or a section of a large medical records department of a major institution. Establishes operations such as statistical units, machine records, archives, automated reimbursement, and individual data base computer system input and report distribution. Plans, organizes, directs, evaluates, and supervises office activities and office services staff in a medical records unit. Determines staffing, equipment, supplies, space, and system needs; develops operating policies and procedures related to office activities such as work flow; develops criteria and procedures to conduct audits of records; researches and analyzes medical reports and prepares qualitative and quantitative reports; collects, prepares, and distributes periodic statistical and status reports and completes survey forms; and collects, duplicates, and processes documents for reimbursement. Performs the employee relations function. Investigates, analyzes, and resolves difficult medical records issues. Develops and provides in service training in medical information systems to professionals and staff. Coordinates activities with other agency, department, and/or hospital activities. Positions functioning as the supervisor of a single unit in a medium size facility develop and implement departmental policies and procedures; develop goals and objectives; and ensure a system for the maintenance, preservation and storage of medical records for accreditation purposes. Make recommendations concerning policies and procedures for the release of medical information in order to ensure confidentiality; serve as a consultant to committees concerning medical records; and may develop departmental budget.

Supervision Given: Provides immediate and general supervision to a group of office services positions which collect, analyze, retrieve, store, present, or interpret medical records or medical data. May also supervise a small number of Medical Records Technicians.

Supervision Received: Receives direction from a Medical Records Manager, Medical Records Director, facility director, or other facility administrator.

Scope: Positions are responsible for supervising medical records staff in a single unit of a small facility or in a section of a large medical records department of a major institution. The work influences the organization, completeness, and availability of information concerning patient records throughout a facility or hospital.

Impact of Actions: Decisions influence the ability of subordinates to effectively and efficiently perform their jobs. Errors in judgement may result in providing incomplete or erroneous information to physicians or others; may compromise the confidentiality of patient records; and can negatively impact patient care, research, education, administrative decisions, reimbursement, and litigation involving the patient, physician and facility.

Personal Contacts: Frequent internal contacts with physicians, nurses, and clinic and emergency room staff regarding the requests and provision of patient records; with physicians, nurses, and students for the purpose of providing in-service training; and with hospital or facility department coordinators for the purpose of giving and receiving information. Infrequent external contacts with Medicare/Medicaid officials, judges, lawyers, patients, police officers, and other governmental officials regarding patient records.

Knowledge: Working knowledge of the rules and regulations governing the preparation and maintenance of medical records; of standard medical and surgical terminology; of medical record filing system and procedures; of disease classification systems and medical information systems; and of supervisory principles and practices.

Skills: None identified for this class.

Abilities: Demonstrated ability to plan, organize, and direct medical information maintenance; to develop policies and procedures; to interpret rules and regulations; to supervise staff; and to communicate effectively, both orally and in writing with medical and administrative staffs.

Licenses or Certification: None; however, some positions may require certification by the American Medical Record Association as Registered Record Administrator, or Accredited Records Technician as required by the Joint Commission's Accreditation Manual for Hospitals.

Education or Training: Graduation from high school or equivalent with additional course work in medical records technology, administration, health information management or a related field.

Level and Type of Experience: Progressively responsible experience in the maintenance of medical records systems.

An equivalent combination of training and experience indicating possession of the preceding knowledge and abilities may substitute for this education and experience.

This class, along with the Medical Records Technician Senior class, replaces the Medical Records Administrator A class. It was established as a result of the statewide Classification Review/Specification Update Program, effective February 1990.