Medical Records Clerk

Purpose of Your Job Position


The primary purpose of your job position is to maintain medical records in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained.


Delegation of Authority


As Medical Records Clerk, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.


Job Functions


Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position.



Major Duties and Responsibilities


Administrative Functions


  • Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.
  • Assist in organizing, planning and directing the medical records section in accordance with established policies and procedures.
  • Assist in the orientation program for all personnel in accordance with our policies and procedures.
  • Assist the Medical Records Consultant as required.
  • Maintain minutes of meetings/files as necessary.
  • Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
  • Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
  • Collect, assemble, check and file resident charts and personnel records as required.
  • Ensure that schedules are followed as outlined for respective shift/area.
  • Ensure incomplete records/charts are returned to nursing service for correction.
  • Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
  • Follow established policies and procedures for the medical records section.
  • Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
  • Maintain a record of authorized information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
  • Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
  • Index medical records as directed by the medical records consultant.


  • Maintain various registries as directed including register for admission and discharge of residents.
  • Type reports for physicians as necessary.
  • Collect charts, assemble them in proper order, and inspect them for completion.
  • Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
  • Assist in admission, transfer and discharge procedures as necessary.
  • Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
  • Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)
  • Assure that medical records taken from the department are signed out and signed in upon return to the department.
  • File active and inactive records in accordance with established policies.
  • Index medical records as directed.
  • Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Clerk.
  • Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.


Committee Functions


  • Perform secretarial duties for committees of the facility as directed.
  • Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.


Staff Development


  • Attend and participate in in-service educational classes and on-the-job training programs as scheduled.
  • Attend and participate in workshops, seminars, etc., as approved.


Safety and Sanitation


  • Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.


Equipment and Supply Functions


  • Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
  • Ensure supplies have been replenished in work areas as necessary.
  • Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of work day, etc.


Resident Rights


  • Maintain confidentiality of all pertinent resident care information to assure resident rights are protected.
  • Assure that residents’ rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are followed.


Working Conditions


  • Works in office areas as well as throughout the facility.
  • Sits, stands, bends, lifts and moves intermittently during working hours.
  • Is subject to frequent interruptions.
  • Works beyond normal working hours, weekends and holidays and on other shifts/positions as necessary.
  • Attends and participates in continuing educational programs.
  • Is subject to cuts, bruises, falls, odors, etc., throughout the work day.
  • May be subjected to infectious diseases, substances, contaminated articles, etc., including the potential exposure to the AIDS and Hepatitis B viruses.
  • Communicates with nursing personnel, and other department personnel.
  • Is subject to hostile and emotionally upset residents, family members, personnel, visitors, etc.
  • Is involved with residents, family members, personnel, visitors, government agencies and personnel, etc., under all conditions and circumstances.


Educational Requirements


  • Must possess, as a minimum, a high school diploma.




  • Must have a working knowledge of medical terminology. On-the-job training provided in medical record procedures.


Specific Requirements


  • Must be able to read, write, speak, and understand the English language.
  • Possess the ability to make independent decisions when circumstances warrant such action.
  • Must possess the ability to deal tactfully with personnel, residents, visitors and the general public.
  • Be a minimum of 18 years of age and of good moral character.
  • Must be knowledgeable of medical terminology.
  • Ability to work harmoniously with other personnel.
  • Ability to minimize waste of supplies, misuse of equipment, etc.
  • Possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices.
  • Be able to follow written and oral instructions.
  • Be knowledgeable in micro-computers, data input and output.


Physical and Sensory Requirements

(With or Without the Aid of Mechanical Devices)


  • Must be able to move intermittently throughout the work day.
  • Must be able to speak and write the English language in an understandable manner.
  • Must be able to cope with the mental and emotional stress of the position.
  • Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
  • Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel.
  • Must be in good general health and demonstrate emotional stability.
  • May be required to lift, push, pull, and move office equipment, supplies, etc., in excess of fifty (50)


  • Must be able to assist in the evacuation of residents.