Ask Caryl: Need for an ASC Medical Records Clerk

Q: In this era of electronic health records (EHRs), is it necessary for my ASC to employ a medical records clerk?

Caryl Serbin: To effectively answer this question, let’s first examine the typical duties of a medical records clerk:

  • Ensures the inclusion of all required documentation in the patient’s EHR within 30 days following the procedure.

  • Scans all paper documentation into the EHR.

  • Obtains all required electronic signatures.

  • Contacts provider’s office for missing history and physical and/or operative note documentation.

  • Provides coder with operative notes, pathology reports and other related documents to ensure optimal coding.

  • Provides requested medical files to persons/agencies according to policies and regulations.

  • Assists with departmental audits and investigations.

  • Maintains quality and accurate records by following approved policies and procedures.

  • Ensures all medical records are protected and kept confidential.

Depending on your ASC's caseload, you may not need an individual solely dedicated to serving as a medical records clerk. You may wish this to be a shared position, assigning the role's responsibilities to one of your other business office employees with the time to perform these duties properly.

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