Medical Records

Under the supervision of the professional nurse, the Medical Records role performs a variety of clerical duties associated with patient care unit operations. This non-exempt position in the Nursing department reports to the Director of Nursing. It ensures smooth administrative support in a hospital setting.

Daily tasks include assembling and processing patient charts, transcribing doctors’ orders per facility policy, and maintaining accurate clinical records. Perform daily chart reviews for incomplete histories and operative summaries, notifying the healthcare team of compliance issues. Obtain closed records and initiate nursing forms for new admissions.

Communicate effectively with the healthcare team, patients, and visitors using telephone and intercom while upholding patient confidentiality. Order unit supplies, distribute them, and keep the nursing station orderly amid high-stress conditions. Promote positive relations with patients, families, and guests using tactful communication.

Adhere to Residents’ Rights, workplace behavior, and dress code guidelines to ensure resident safety. Work in a general office environment with a schedule including weekends, evenings, and holidays. Gain hands-on experience in medical record management within a supportive healthcare team.