The Health Information Management Chart Documentation Analyst & Abstractor monitors the completion and accuracy of the medical record. The position utilizes hospital policies and procedures to perform analysis of medical records for documentation requirements as specified by federal and state regulatory agencies, to include The Joint Commission, and the Medical Staff Rules and Regulations.

The Health Information Management Documentation Analyst & Abstractor reports directly to the Director of Health Information Management.

1. Interacts with physicians by telephone, mail and face to face to ensure compliance with chart completion requirements.

2. Maintains accurate statistical data on chart completion requirements. Prepares
    necessary delinquency reports and correspondence.

3. Processes rejected orders from CPOE.

4. Performs analysis of discharge records to ensure all documentation requirements
    met.

5. Calculates and abstracts data for trauma registry and documentation quality
    improvement organizations into approved software.

6. Performs Master Patient Index (MPI) functions for historical patient record
    accuracy.

7. Retrieves paper portion of record from clinical service areas and accounts for all
    patient records.

8. Ensures all documentation is prepped, scanned, uploaded and available in the
    electronic medical record. Spot checks scanned records to assure quality before
    shredding documents.

9. Processes the closed chart work list as necessary.

10. Assists with release of information as needed.

11. Assists off-site coders as needed.

12. Calculation and entry of injection and infusion charges for ED and Observation
     accounts.

13. Perform other job as assigned.

1. Education:
  a.) High School or equivalent.
  b.) Post high school education in Health Information Technology or equivalent

2. Licensure/Certification:
  a.) None required.

3. Work Experience:
  a.) Experience in medical office or hospital setting. Two years preferred or
      equivalent education.