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Career Story: Health Information Secretary At A Nursing Home

Health Information Secretary At A Nursing Home

Job Title: Health Information Secretary

Type of Company: A not-for-profit long-term care facility

Education: attended, business school

Previous Experience: I worked at a hospital in the Medical Records Department and currently work in a nursing home.

Job Tasks: My job is very diversified. I am responsible for handling all patient charts, ordering lab work, x-rays and medical appointments and setting up the physicians' schedules so the patients are seen either monthly or bi-monthly. I also am responsible for handling all discharge records. I have to enter all the diagnoses that are related to the patients' admission as well as the type of insurance they have. Thankfully, I do not get involved with any billing.

This is a very rewarding job and the patients are always so easy to please. I have been in this position for 24 years and really enjoy it. No two days are alike. One day you may have a few admissions and other days none. I do a lot for the nurses on the units. I am in a facility that has sixty patients so I am in charge of doing chart audits to see if the different departments are completing their paperwork. I also have to keep track of when the patients need their bloodwork done or see their eye doctor, dentist, etc. State regulations require that patients have bloodwork done at least once a year, and they need to be on a schedule to see other providers. I have to make sure that when the state comes in for their annual inspection that all charts are up-to-date.

If I have an admission I have to set the chart up with the correct paperwork and enter the diagnosis codes into the computer. I get the diagnosis from the Hospital Discharge Summary. It takes a little research and can be very interesting. You get to learn a lot about symptoms and procedures. When a patient is discharged I have to file his chart away and make sure that we keep it for 10 years. This is our state code. If you like a fast-paced job and job security in the health care field, this is for you.

Best and Worst Parts of the Job: Trying to get everything done in an eight-hour day! Everyday is different so it takes a lot of planning on my part.

Job Tips: I would recommend that you get a two-year degree in Medical Records first. This should include a course on diagnosis coding which is very important in today's world. All insurance companies use these codes to bill correctly. You should be a very organized person and like to work with people.

Additional Thoughts: I feel that a lot of people would think this job was boring. But it isn't. I don't have much time at my desk because I am on the nursing units a lot, working with the nurses and the doctors when they come in to see the patients. And, as the years have gone by, my job has changed to include other things. A lot of my job is now done on the computer.

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