MEDICAL RECORDS TECHNICIAN - PRN (as needed)
SUMMARY: Serves as a medical records technician to process and maintain inpatient, outpatient or ambulatory procedure unit medical records. Required to compile, extract or locate medical information/data to ensure medical record accountability and availability in accordance with DoD and medical service standards.
- UNIQUE MILITARY HEALTH CARE SYSTEMS/PROCEDURES:
- Armed Forces Health Longitudinal Technology Application (AHLTA)
- Composite Health Care systems (CHCS) and/or MHS GENESIS
- Defense Enrollment Eligibility Reporting System (DEERS);
- Military Filing System - by sponsor social security number, terminal digit order, color-coded and blocked filing system.
- Contents of a military medical record, layout, sections, family member prefix designation, forms used in a MTF, and the medical record tracking procedures.
- Health Artifact and Management Solutions (HAIMS)
- PERFORMANCE OUTCOMES:
- Initiates and maintains medical records in accordance with prescribed directives.
- Files military forms documenting patient care into patient medical records.
- Conducts daily pull, delivery and retrieval of patient records.
- Searches for missing paperwork or records. Requests information pertaining to patient treatment to place in the medical record.
- Prepares reports regarding record statistics as necessary. Participates in records review as part of the facility?s quality assurance program and in accordance with accreditation standards.
- Reviews records to ensure proper and complete documentation.
- Retires medical records in accordance with Air Force guidelines.