Description
Organize, maintain, and retrieve patient medical records in paper and electronic systems. File and index clinical documents per HIM policies, ensuring accuracy, timely access for authorized users, and strict HIPAA compliance.
- • Create new patient charts and add clinical documents to existing records.
- • Collect documentation from units, clinics, and outside providers for filing or scanning.
- • Review and sort incoming materials to determine correct patient, encounter, and document type.
- • Index and file documents in the EHR or paper charts by patient, date, and category per HIM policies.
- • Verify and apply patient identifiers, account numbers, and barcodes before scanning or filing.
- • Scan paper documents into the EHR and verify image quality and legibility.
- • Track chart pulls, locations, and returns to ensure timely availability for care teams.
- • Retrieve records for clinicians and authorized staff and re-file promptly after use.
- • Process Release of Information requests, confirming authorization and identity before disclosing PHI.
- • Provide information on record status and location to authorized requestors while protecting confidentiality.
- • Maintain logs and generate reports on chart movements, ROI activity, scanning volumes, and deficiencies.
- • Conduct quality checks for completeness, correct indexing, and required signatures; flag deficiencies for completion.
- • Purge, archive, or securely destroy records in accordance with retention schedules and legal requirements.
- • Retrieve archived records from off-site storage or microfilm when needed.
- • Assist with updates to filing, indexing, and retention procedures and forms.
- • Enter and update metadata in EHR and document management systems to support search and retrieval.
- • Identify possible duplicate or misfiled records and escalate for correction or merge per policy.
- • Handle office tasks such as phones, mail, and faxing; safeguard PHI and work within HIPAA guidelines.
- • Collect and record ROI fees when applicable and submit for processing.
- • Support audits, chart completion, and accreditation surveys by locating and preparing records.
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O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
