Terracina Grand
  • Nursing Services
  • Naples, FL, USA
  • Part Time


The primary purpose of this position is to assure that medical records are maintained in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained.

Essential Job Functions Duties and Responsibilities

Medical Records

1.     Plan, develop, organize, implement, evaluate, and direct the medical records section in accordance with established policies and procedures. Includes department policies and procedures, job descriptions, etc.

2.     Review discharge and death records, as well as records on the nursing units.

3.     Collect, assemble, check, and file resident charts and personnel records. 

4.     Maintain a record of authorized information taken from charts/records (i.e., type information, name of recipient, date, department, etc.).

5.     Abstract information from records as authorized/required for insurance companies, Medicare, etc.

6.     Prepare medical records for court trials as required.

7.     Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. Attend such meetings as may be necessary or appropriate.

8.     Assist in the development of and participate in inservice, orientation classes, and onthe job training programs.

9.     Ensure that work areas are clean and that records are properly stored.

Required Knowledge, Skills and Abilities

Must possess the ability to make independent decisions, follow instructions, and accept constructive criticism.  Must be able to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.  Must be able to work with ill, disabled, elderly, and emotionally upset people within the facility. Must be able to speak, write and understand English in a manner that is sufficient for effective communication with supervisors, employees, residents, and families.

Education and Experience

High school diploma or equivalent.

Prefer experience in Health Information Management department.

Terracina Grand
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