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Career Story: Nurse And Director Of Medical Records At A Nursing Home

Nurse And Director Of Medical Records At A Nursing Home

Job Title: Licensed Practical Nurse/Director Of Medical Records

Type of Company: I work for a skilled nursing home that provides short-term care and rehabilitation so people can continue to get stronger before going home. But there are also people living here long-term!

Education: LPN Certificate, Medical University of South Carolina

Previous Experience: I was an assistant to an LPN in a doctor's office, with both clinical and administrative duties, before I moved to a nursing home, first as a nurse and then as the head of the medical records department.

Job Tasks: I supervise one assistant in my office. I am a department head which is a management position so I also oversee all staff when I work as Manager on Duty (M.O.D.) My department does the data entry of demographics and physician orders into the computer. I am responsible for any and all medical records generated for the patient during his stay. We protect the records and the patient's privacy. The management team is part of the "We Care Team", so my work day starts with visiting a few of the patients to ensure that there are no problems or questions that need to be resolved. I then attend a morning meeting to review the previous twenty-four hours. I am responsible for the census which means knowing everyone that is a patient in our facility. After the meeting, my assistant and I work on the data entry items, do audits to assure that the nursing documentation reflects the care given and secure the closed records and help to create packets of admission paperwork for new admits. I handle any records requests that come in. I interact with patients, families, co-workers and physicians. I work with them to create a caring team that provides quality care.

Best and Worst Parts of the Job: The best part of my job is interacting with the patients: saying hello and seeing their smiles, hearing their life stories, both happy and sad. In a nursing home, the patients are generally called "residents" even if they're there for just a couple of days. This encourages a more home-like atmosphere.

The worst part of the job is there is so much paper work. There can be thousands of pages of medical records for one resident!

Job Tips:
1. You do not need to be an LPN to be a director of medical records. It works to my advantage in some ways, though, because the medical knowledge I have helps me to interpret the doctor's hand writing and what medications are used for.

2. Take basic computer courses, medical terminology, coding classes for diagnosis and billing. Work hard to obtain the Health Information Certificate which allows for an experienced medical records person to work as a consultant and earn more money.

Additional Thoughts: Be aware that the medical record will eventually be paperless. Larger institutions have already started the conversion. The more computer knowledge you have the more qualified you will be to do the job.

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