Health Information Tech

Founded in 1910, Dignity Health - Community Hospital of San Bernardino is a 347-bed, acute care, nonprofit, community hospital located in San Bernardino, California. Known for its programs in maternity care and pediatrics, behavioral health and long-term subacute care for adults and children, the hospital also includes inpatient and outpatient surgery. The hospital shares a legacy of humankindness with Dignity Health, one of the nation’s five largest health care systems. Visit here https://www.dignityhealth.org/socal/locations/san-bernardino for more information.

One Community. One Mission. One California 

This position is responsible for coordination of medical record control functions to ensure the timeliness, accuracy, integrity, and reliability of data and information created for all patients treated within the facility. This position must accurately analyze and interpret the contents of the medical record for the purpose of determining completeness of the entries, monitoring record completion requirements of the Medical Staff Bylaws, Rules and Regulations, and completing paperwork necessary to register births and fetal deaths. Processes medical records in various formats including paper, electronic, and scanned media. Uses computerized systems to track medical record locations and completion status. Assists patients and external requestors in accessing Protected Health Information in compliance with laws, statutes, and organization policies and procedures. Assists physicians in the accurate completion of medical records both concurrently and retrospectively. Works with Nursing Staff on the units to assist in completing the medical record timely. This position requires the full understanding and active participation in fulfilling the Mission of Community Hospital of San Bernardino. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support Community Hospital of San Bernardino's strategic plan and the goals and direction of the quality improvement/process improvement activities.

• Receives and processes medical records at the end of the encounter, including picking up charts, accounting for charts using computerized lists of discharges, and working with staff on the Nursing Units and in Departments to locate charts not received. Includes the use of computerized systems to track the receipt and location of medical records throughout the facility.
• Performs concurrent analysis of medical records on the Nursing Units to achieve chart completion prior to patient discharge, including flagging missing dictation and signatures, filing loose material in the chart, monitoring the correct order of the chart, thinning patient charts that have become too large for the chartback.
• Assembles and analyzes medical records according to Dignity Health and hospital policies and rules of the Medical Staff. Includes use of computerized systems to track physician completion deficiencies. Reanalyzes medical records for elements of completion after the records have been pulled for physician completion. Forwards paperwork to appropriate Departments or facilities as required in hospital and department policies and procedures.
• Maintains the incomplete, permanent, and archival files of the hospital, including filing records into the correct locations based on the stage of completion and/or age of the record; assembling loose material into the correct encounter records. Includes the use of computerized systems to create encounter volumes and track records moved between locations within and outside the HIM Department.
• Retrieves medical records for patient care, administrative use, release of information, hospital reimbursement, and other legitimate uses of the medical record. Locates the correct medical record from locations throughout the HIM Department and hospital. Assesses the legitimacy of requests for access to medical records based on Dignity Health and hospital policies.

• One (1) year of previous clerical experience in a Health Information Management setting in a hospital required.
• Experience working directly with physicians and clinical care providers preferred
• Accurate key stroke skills
• Ability to file alphabetically, numerically, and in terminal digit order
• Working knowledge of medical terminology