Job Specification

Purpose of Position :

To provide accurate and high quality production of a variety of medical/clinical records using computer and to update and maintain a clinical database
by performing data entry and retrieval functions; to provide clerical support to the Clinical Information Systems and Quality Improvement department;
and to monitor, review, and analyze client casebooks ensuring accurate case records are completed and maintained in compliance with regulatory and
legal requirements. To provide relief at Switchboard/Reception area.

Duties / Responsibilities :

1. To provide accurate and high quality production of a variety of medical/clinical records using computer and to update and maintain a clinical database
(Facility Client Information System) by performing data entry and retrieval functions:
- Creating a high volume of clinical task management records based on clinical dictation submitted by multi-disciplinary professionals within electronic
client database
- Proof reading (both on screen and hard copy) to ensure accuracy and completion;
-Verifying information through the Facility Client Information System; clinical file or author;
- Receiving incoming calls and handling inquiries from clinicians, programs and Clinical Information Systems staff regarding computer/dictation system
technology problems with users/report persons, or providing instructions re: proper procedures to follow when dictating reports;
-Formatting and setting up of standardized clinical report templates; form letters and forms based on input from programs and reporting manager;
- Ensuring that appropriate documentation is finalized and transferred to the appropriate professional and living unit staff;
- Handling priority requests according to established timelines;
-Scanning and uploading of clinical medical reports into electronic Facility Client Information System according to established guidelines;
2. To provide Clerical/Reception support to CPRI, Clinical Information Systems and Quality Improvement Department by:
- Completing bi-annual inventory of departmental physical property
- Providing photocopy service to Program Managers and Clinical staff, ensuring copies are distributed as
requested and arranging for large volume photocopy requests to be sent to outside service provider.
- Sending and receiving faxed material for facility following established local guidelines related to security of confidential information and referring
unusual or atypical requests to Manager; distributing incoming faxed material to designated recipient;
- Maintaining and ordering of office supplies for the department;
- Updating departmental manuals;
- Typing routine correspondence, etc;
-Processing and mailing of photocopied reports to external agencies, parents, etc.;
- Sorting and delivering of incoming/internal mail to the facility
-Maintaining Excel database of correspondence requests and Facility Client Information System consents to release of information to external sources;
- Providing backup to Intake, Admissions and Switchboard/Reception and other areas as needed;
- Providing assistance to Intake Coordination Clerk, Program Administrative Assistants and Medical Administrative Assistants for consents, reports,
pulling Casebooks, general clerical duties
- Provide assistance to the Nursing Clinic, i.e. Booking of Appointments
-Receiving all incoming business mail for the Facility each day, sorting and distribution of mail
3. To monitor, review and analyze client casebooks ensuring accurate case records are completed and maintained in compliance with regulatory and
legal requirements
- Reviewing and analyzing the outpatient client casebooks for accuracy and completeness of documentation following initial assessment and at
prescribed intervals according to established standards, procedures and legislation;
- Reviewing and checking all client casebooks concurrently and at the time of discharge, to ensure all components of the casebook are complete,
including signatures, authorizations, consultations, admission/discharge summaries, treatment plans, labs etc;
- Accessing and reviewing incoming transcribed reports and noting date of last contact and their completion against deficiency list, where appropriate;
-Assisting professional staff by providing information, explanation, or clarification of quantitative analysis procedures and local documentation policies,
utilizing standards set by the facility and department and legislation;
-Responding to inquiries from external transcriptionists and internal professional, manager and administrative staff regarding documents, formats,
contents and titles;
- Collecting of data and preparing special reports as required; Printing of Caseload I Dally Log reports for Physicians

Knowledge :

Job requires knowledge of:
- Departmental policies and procedures related to Clinical Information Systems and Quality Improvement department in order to process assigned work;
- Filing and office procedures (alpha and numeric filing systems);
- Switchboard Console to provide relief for Switchboard/Reception Area;
- Emergency Codes to ensure emergency calls are responded to efficiently at the Switchboard/Reception Area;
-Word processing technology, software and equipment and the visual acuity to discern report formats;
- Clinical Information Systems procedure manuals, MCYS Retention Schedules, and medicaVclinical terminology and programs;
- Legislation requirements of the Child and Family Services Act, the Freedom of Information and Protection of Privacy Act; and the Personal Health
Information Protection Act; as well as knowledge of the policies, procedures and practices in the areas of Clinical Information Systems, Intake,
Admissions in order to collaborate and/or respond to inquiries regarding work assignments.
- Casebook assembly procedures and knowledge of frequently used medical terminology in order to effectively carry out responsibilities.
- Extensive knowledge of MS Office Excel, Word and the ability to input and update the Facility Client Information System/ database management
systems environments.

Skills :

Job requires skills of:
- Oral and written communication skills to interact with professional staff and in particular to act as the monitor for incomplete/deficient reports; and to
explain existing, revised or new procedures relevant to accreditation and/or facility documentation standards in an understandable and positive manner.
- Problem solving skills to investigate non-routine work problems and determine any situations that may have impact on one?s own workload, in the
department or facility.
-Organizational skills to co-ordinate and manage information of data and to plan and prioritize own workload within established time frames. Tasks are
expected to be completed despite short notice or fluctuating peaks in workload
- lnterpersonnal skills to work collaboratively with personal contacts i.e. parents/guardians of children or the child and/or external stakeholders
requesting information; multiple clerical and administrative duties guided by existing policies and procedures, variety of multi-disciplinary professionals,
staff, external agencies. Non-routine occurrences may demand flexibility and responsiveness.
-Keyboarding skills to use a computerized Facility Client Information System and to perform limited word processing functions.
Technical Skills:
- Typing to government standards

Freedom of Action :

Work is performed under general supervision and exercises some judgement in setting own work priorities to meet deadlines; data input workload must
be performed as requested.
- Errors in input could result in inaccurate data being generated from databases; errors would not easily be detected and continued errors would
jeopardize the reliability of the databases. Errors in release of information could result in Privacy Breach of Information, would not easily be detected
and could result in facility fines and/or investigation with the Information Privacy Commissioner of Ontario.
- Judgement is exercised in determining in which situations clarification is needed from the individual clinician where input data is unclear or absent.
-Analysis/ decision making is required to determine the most appropriate type and format of report to be used, from the authors description or lack
thereof. Incumbent is expected to use available resources to solve routine problems.
- Judgement is exercised to ensure the author has met the criteria for completed reports; or due either to the complexity of the assigned work; or the
balance of the completion of priority assignments with daily work; and to refer any unusual/ contentious issues or complex matters to the Manager.
- Job requires working in accordance with internal department procedures. Work is covered under facility and Ministry policies and procedures and
legal requirements but judgement may be required if situation is not covered by established practice.
- Job requires ensuring to verify the identity of the legal guardian and ensuring to release information in adherence with Privacy legislation and Ministry/
Facility policies.