Guadalupe Rubi

As a Medical Records Director, I am responsible for ensuring the integrity and accuracy of medical documentation, ensuring compliance with state regulations, and supporting healthcare providers in maintaining proper patient records. My role includes auditing, training, and assisting healthcare professionals to ensure efficient use of software systems, while ensuring the secure handling and transfer of sensitive patient information. Below is a detailed overview of my responsibilities:

• Daily Audits: Conduct daily audits for nurses, CNA's, and doctors to ensure that all charts are in compliance with state regulations.
• Chart Management: Close discharge charts and scan them into Point Click Care (PCC); scan and attach any relevant records to the patient's profile.
• Record Management: Gather, review, and organize patient records for various requests, including subpoenas & ADR's. Ensure that all records are properly scanned, stored, and compliant with healthcare laws.
• Documentation & Compliance: Ensure compliance with federal and state laws related to medical record documentation, including reviewing open and closed records for adherence to policies.
• Follow-up & Coordination: Follow up with doctors on pending orders that require signatures. Maintain monthly visits to Skilled Nursing Facilities for ongoing record updates and coordination.
• Record Transfers & Submissions: Facilitate secure transfer of patient records to other healthcare providers and submit records to Long Term Care Insurance providers.
• Meetings & Collaboration: Attend relevant meetings to stay informed on updates and changes within the healthcare system and document management procedures.
• Implemented efficient record storage and retrieval systems to meet legal retention requirements and improve accessibility.
• Ensured consistent compliance with medical record documentation policies, reporting findings to nursing services directors.

As a Medical Records Director, I am responsible for ensuring the integrity and accuracy of medical documentation, ensuring compliance with state regulations, and supporting healthcare providers in maintaining proper patient records. My role includes auditing, training, and assisting healthcare professionals to ensure efficient use of software systems, while ensuring the secure handling and transfer of sensitive patient information. Below is a detailed overview of my responsibilities:

• Daily Audits: Conduct daily audits for nurses, CNA's, and doctors to ensure that all charts are in compliance with state regulations.
• Chart Management: Close discharge charts and scan them into Point Click Care (PCC); scan and attach any relevant records to the patient's profile.
• Record Management: Gather, review, and organize patient records for various requests, including subpoenas & ADR's. Ensure that all records are properly scanned, stored, and compliant with healthcare laws.
• Documentation & Compliance: Ensure compliance with federal and state laws related to medical record documentation, including reviewing open and closed records for adherence to policies.
• Follow-up & Coordination: Follow up with doctors on pending orders that require signatures. Maintain monthly visits to Skilled Nursing Facilities for ongoing record updates and coordination.
• Record Transfers & Submissions: Facilitate secure transfer of patient records to other healthcare providers and submit records to Long Term Care Insurance providers.
• Meetings & Collaboration: Attend relevant meetings to stay informed on updates and changes within the healthcare system and document management procedures.
• Implemented efficient record storage and retrieval systems to meet legal retention requirements and improve accessibility.
• Ensured consistent compliance with medical record documentation policies, reporting findings to nursing services directors.
• Oversaw secure transfer of patient records to other health care providers to support requests and authorizations.
• Evaluated requests for information and maintained and tracked releases to comply with federal and state laws.

As a Medical Records Coordinator, I play a crucial role in maintaining and organizing patient data within the Point Click Care (PCC) system, ensuring compliance with state regulations, and supporting healthcare professionals. I am responsible for entering patient admissions, performing daily audits, and managing medical records, while also training staff on the software and record-keeping processes. My role requires attention to detail, excellent communication skills, and the ability to support healthcare providers in using the system efficiently.

• New Admissions: Create new patient profiles in Point Click Care (PCC) and enter all admission orders accurately.
• Daily Audits: Conduct daily audits for nurses, CNAs, and doctors to ensure medical charts are accurate, up-to-date, and compliant with state regulations.
• Census Management: Update the daily census in Point Click Care to reflect accurate patient data.
• Chart Review & Compliance: Audit patient charts regularly to ensure compliance with state and federal regulations, closing discharge charts and scanning them into Point Click Care.
• Record Management: Scan and attach any relevant records to patients' profiles in PCC, ensuring all records are complete and accessible.
• Training & Support: Provide ongoing training to new doctors and unit assistants on how to use Point Click Care effectively, including how to scan and enter patient data and admission orders.
• Record Requests: Gather and review patient records for various requests, including subpoenas, insurance appeals, and legal requests.
• Communication & Follow-up: Follow up with doctors on any pending orders that need signatures. Maintain regular communication with the Skilled Nursing Facility to ensure accurate and up-to-date records.
• Documentation Submissions: Fax records that require signatures and submit necessary documents to Long Term Care Insurance providers.
• Collaboration: Attend meetings to stay updated on changes in procedures, software updates, and compliance requirements.
• Streamlined patient record entry and auditing processes, ensuring compliance with healthcare regulations.
• Led successful training initiatives for healthcare staff, enhancing their proficiency in using the Point Click Care software.
• Played a key role in maintaining accurate and compliant patient records, contributing to the efficient operation of healthcare facilities.

As a Medical Records Coordinator, I am responsible for managing patient data within the Point Click Care (PCC) system, ensuring compliance with state regulations, and providing support to healthcare professionals. My role involves creating new patient profiles, entering physician orders, performing audits, and maintaining accurate records. I also assist nurses and doctors with any software-related queries and ensure that all record requests are fulfilled promptly.

• Create New Admissions Profiles: Set up and enter all relevant patient information and admission orders into Point Click Care (PCC).
• Physician Orders: Accurately enter physician orders into the PCC system.
• Daily Audits: Conduct daily audits of patient charts for compliance with state regulations and facility policies.
• Census Updates: Regularly update and maintain the daily patient census in the PCC system.
• Chart Compliance: Audit patient charts to ensure they meet regulatory standards and close discharge charts upon completion.
• Support and Training: Assist nurses and doctors with any questions related to Point Click Care and provide guidance on using the system effectively.
• Record Requests: Gather and organize patient records for various requests, including legal subpoenas and other documentation requests.

• Ensured accuracy and compliance of patient data within the PCC system.
• Played a key role in maintaining up-to-date records and supporting medical staff in using the software efficiently.