Regulations (e g. Mental Health Act, Public Hospitals Act, Personal Health Information Protection Act, Criminal Code of Canada), Canadian Institute for Health Information




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NameRegulations (e g. Mental Health Act, Public Hospitals Act, Personal Health Information Protection Act, Criminal Code of Canada), Canadian Institute for Health Information
A typeRegulations
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Title: Health Record Technician


Classification: Health Records Technician

Department/Program: Clinical Information Services

Bargaining Unit: OPSEU

Salary: $24.65 to $27.78 per hour

Hours: Full Time - 37.5 hr/wk
Waypoint Centre for Mental Health Care, formerly the Mental Health Centre Penetanguishene, is a 312-bed psychiatric hospital situated on Georgian Bay. The hospital is recognized as progressive in the provision of exceptional care, research of severe behaviours associated with mental illness and for its contributions to awareness and understanding. Waypoint is an official University of Toronto teaching hospital and university based research academic centre. We are now recruiting for a dedicated individual to provide expertise in information and records management, clinical classifications and terminologies, data and information standards and information systems; maintaining a complete clinical/medical record and providing accurate diagnostic and statistical information to the Canadian Institute for Health Information (CIHI), to the hospital’s Administration and the Ministry of Health and Long Term Care (MOHLTC).
Qualifications: Successful completion of a Health Information Management (HIM) diploma program and certification recognized by the Canadian Health Information Management Association (CHIMA) or other degree/diploma in HIM or health sciences. Candidates challenging certification in 2011 will be considered.
Knowledge of:

  • workflow of the clinical information services department, focusing on health care data and the management of health care information

  • theory and practice of health information management (removed because we say it above)

  • legislative requirements, standards, guidelines (e.g.hospital and departmental policies and procedures), legislation/regulations (e.g. Mental Health Act, Public Hospitals Act, Personal Health Information Protection Act, Criminal Code of Canada), Canadian Institute for Health Information

  • the International Classification of Diseases (ICD-10-CA/CCI) and DSM IV to assign an accurate code based on documentation in the clinical record; medical terminology (anatomy & physiology)

  • computer software packages (MS Word, Excel, Outlook, Power Point); manage databases, (Admission Discharge Transfer (ADT) system and Central Dictating System) and the information flow within the organization; scanning software and hardware for conversion of paper records to an electronic medium

  • quality and risk management practices ensuring clinical documentation is accurate, complete and timely;

  • information systems, how they integrate with each other in order to help transition from paper records, ensuring standardization and best practices for the electronic health record and the availability of required health information for the future.


Position also requires organizational, analytical, interpersonal, verbal & written communication skills as well as strong customer service orientation

Position requires proficiency in English and French. Less qualified candidates may be considered.
Apply by June 6, 2011 to Job ID WC11-51

Talent Management e-mail Careers@waypointcentre.ca

To view detailed job information including job specification and selection criteria

please visit www.waypointcentre.ca

Applicants are thanked for their interest in this position, however,

only applicants selected for interview will be contacted.

Candidates will identify when accommodation is required

to enable him/her to compete on an equal basis


POSITION DESCRIPTION REPORT (PDR) - OAG


JD# Rev. Date March 15, 2010

1.

Position Information










Position Title

Health Records Clerk

Position Code

05-9565-60

























Bargaining Unit

OPSEU




Location

Penetanguishene

Class

Health Records Clerk



















Supervisor’s Position Title

Director, Clin. Info. Serv.










Supervisor’s Position Code

05-9565-55














































Provides group leadership to:







No. of Positions 0

No. of Employees 0

2.

3.

Purpose of Position

To maintain a complete inpatient and outpatient clinical record; to ensure accurate filing and easy retrieval of records for both paper and microfilmed documents; completing registration and discharge processes to ensure accurate quality diagnostic and statistical data is collected in various databases e.g. Admission, Discharge, Transfer (ADT), Management Information Systems (MIS) and submitted to the hospital’s Administration and Ministry of Health and Long Term Care; to assist with other procedures in the department in order to keep workload up to date.
Duties/Responsibilities

1. Maintain data quality standards by assisting and facilitating the process for MIS and ADT data collection. Problem-solve to resolve discrepancies and/or errors in admissions/registrations. Identify risk management issues and opportunities for improvement and communicate appropriately. Maintain the integrity of the patient record by ensuring completeness and accuracy of the clinical record by filing clinical records and loose reports; perform quantitative and qualitative analysis on all patient records; maintain the chart tracking system for all clinical records moving to and from the department.
2. Protect patient privacy and confidentiality in accordance with departmental, hospital policies and legislation by collecting, using and/or disclosing personal health information on a need to know basis in order to carry out the duties of the position; completing annual privacy refresher and annually signing of statements of compliance to privacy and confidentiality.
3. Answering the telephone, assisting callers or referring them to the appropriate person or department; retrieve charts, microfilm, digital records as requested by programs, departments, clinicians, medical staff; organize and schedule medical appointments for patients; order and maintain stationery and office supplies.
4. Archives: Prepare clinical records for microfilming/scanning process; update and maintain accurate logs; reconcile film/digital media with logs to ensure all clinical records and information have been archived appropriately.
5. Provide customer service to facility staff, patients and external agencies as required. Provide orientation, training and respond to inquiries from all hospital staff to records and information management processes. Provide support services and back up to other Clinical Information Services departmental staff during co-workers absences and during peak times.
6. Establish on-going goals and objectives of the position and prioritize with Director CIS ensuring the quality, integrity, accuracy of the clinical record and clinical and statistical data; identify and participate in continuous quality improvements processes; participate and assume a clinical record resource role on hospital committees and/or teams.
7. Observe the requirements of the Occupational Health & Safety Act & Regulations.
8. Professional Development: Identify and meet own professional and personal growth needs including maintaining the registration standards set out by the Canadian Health Information Management Association (CHIMA), (CIHI) and Ministry of Health & Long Term Care (MOHLTC).

9. Update and maintain procedure manual.
Manager has the right to assign additional duties.


4.

Staffing and Licensing Requirements:

Keyboarding skills to 50 wpm standard. Completion of a recognized medical terminology course is preferred.


5.

Knowledge

Knowledgeable and observing all legislative regulations, Accreditation Canada guidelines including hospital and departmental policies, Mental Health Act, Personal Health Information Protection Act, Health Care Consent Act, Public Hospitals Act, Criminal Code of Canada and Canadian Institute for Health Information (CIHI) guidelines; Knowledgeable in the workflow of health information management in order to answer inquiries and retrieve records for physicians , program staff and other healthcare facilities; Knowledgeable of theory and practice of health record administration including health information management, medico-legal aspects of health information including the Mental Health Act, Health Information Protection Act 2004, Public Hospitals Act, Criminal Code of Canada, Accreditation Canada standards and Canadian Institute for Health Information (CIHI) and best practices as they apply to clinical record recording, filing, psychiatric certificates (legal status), capacity to treatment and manage property as well as knowledge of health record policies & procedures in order to ensure the integrity and accuracy of the information within the clinical record therefore contributing effectively to supporting patient safety and minimizing risk to the hospital; knowledge of medical terminology, anatomy and physiology, pharmacology in order to distinguish the differences in the various forms and reports, the filing order and to translate information collected at registration into a form of numerical code; knowledge of computer software in order to input and retrieve patient information, statistical data, create and manipulate spreadsheets, create graphics and presentation materials and create reports for hospital Administration, by utilizing and managing the patient information systems (Admission, Discharge Transfer), document management and electronic mail.

6.

Skills

Position requires: analytical thinking and attention to detail to effectively collect patient information to assist in the production of statistics and clinical data reports and to maintain and carry out current record keeping practices including alphabetic and numerical filing accuracy ; organizational skills to manage and prioritize multiple tasks and meet objectives and deadlines; verbal and written skills to express ideas effectively in individual and group settings; adjusting language and terminology to the characteristics and needs of the audience e.g. physicians, clinicians, external stakeholders; interpersonal skills to maintain effective relationships with co-workers and customers, to network with other hospitals on a routine basis to determine present and future opportunities for improvement, and assisting with orientation and education of new staff in relation to records management including data quality, legislation and archiving; customer service orientation in order to proactively develop customer relationships, anticipate and provide solutions to customer needs and to continuously give high priority to customer satisfaction. Keyboarding skills and the ability to operate standard office equipment.

7.

Freedom of Action

Under the general supervision of the Director, Clinical Information Services the incumbent works within the framework of the hospital, the Canadian Health Information Management Association procedures, best practices and relevant legislation. Job requires seeking direction with Director on non-routine matters. Judgment is exercised in determining priorities, planning and organizing the assignments to meet objectives and deadlines and to ensure the quality and integrity of the information by reviewing clinical data in coordination with the Director and the Clinical Data Analyst. Judgment is exercised in determining appropriate actions relevant to the collection, use and disclosure of personal health information as prescribed by current legislation. Work is checked for accuracy and timeliness by regular audits conducted by the Director.

8.

Signatures

Manager



Date





9.

Class Allocation



Class Title

Health Records Clerk




BU

OPSEU

Effective Date

March 15, 2010













































































































Signature of Authorized Evaluator



Date

Authorized Evaluator’s Name
Jane Robitaille – Manager, Human Resources





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