Reporting To:
1. Direct: Incharge Medical Records
2. Indirect: Unit Head / Executive Quality / Assistant Manager Quality
Qualifications & Experience
1. Diploma in Medical Records Technology (DMRT), B Sc, Bachelor of Medical Records Science (BMRS)
2. Fresher’s or Minimum 2 years of experience in medical records department in an Institution with well maintained medical records
Key Result Areas
1. To ensure security of all patients Medical Records and data.
2. To ensure completeness of all medical records on time
3. Updating the appropriate diagnostic codes for all the IP files according to WHO ICD 10CM
4. Updating the appropriate procedural codes for all the IP files according to CPT (Current Procedural Terminology)
Knowledge and Skills
1. Previous experience in a medical records Department
2. Awareness of ICD -10 CM and CPT coding
3. Competency in all Medical Record Modules
4. Strong customer service skills
5. The ability to multi-task
6. Statutory requirements of MRD
7. Using the Hospital emails
Exclusive job Responsibility
1. Receiving phone calls and reply for the calls on the department and patients related activities
2. To take printout of the scheduled appointments for consultation for the next day and make sure the appointment files are scanned and uploaded in the HMIS & Quality check is done
3. Issuing Inpatient files to doctors or User Department for the audit purpose on request and assisting for doctors in special studies / research as required
4. Receive all the reports from front office, emergency ward, procedure room, and medical transcription. Scan the document and upload under the respective patient’s PRN in HMIS.
Reporting To:
1. Direct: Incharge Medical Records
2. Indirect: Unit Head / Executive Quality / Assistant Manager Quality
Qualifications & Experience
1. Diploma in Medical Records Technology (DMRT), B Sc, Bachelor of Medical Records Science (BMRS)
2. Fresher’s or Minimum 2 years of experience in medical records department in an Institution with well maintained medical records
Key Result Areas
1. To ensure security of all patients Medical Records and data.
2. To ensure completeness of all medical records on time
3. Updating the appropriate diagnostic codes for all the IP files according to WHO ICD 10CM
4. Updating the appropriate procedural codes for all the IP files according to CPT (Current Procedural Terminology)
Knowledge and Skills
1. Previous experience in a medical records Department
2. Awareness of ICD -10 CM and CPT coding
3. Competency in all Medical Record Modules
4. Strong customer service skills
5. The ability to multi-task
6. Statutory requirements of MRD
7. Using the Hospital emails
Exclusive job Responsibility
1. Receiving phone calls and reply for the calls on the department and patients related activities
2. To take printout of the scheduled appointments for consultation for the next day and make sure the appointment files are scanned and uploaded in the HMIS & Quality check is done
3. Issuing Inpatient files to doctors or User Department for the audit purpose on request and assisting for doctors in special studies / research as required
4. Receive all the reports from front office, emergency ward, procedure room, and medical transcription. Scan the document and upload under the respective patient’s PRN in HMIS.
1. Assembling and numbering of IP/Daycare files as per the checklist No IP assembling (NUH-S-F-A-01 ) and Daycare (NUH-S-MRD-CL-1A)
2. Conduct ward rounds on a daily basis & circulate the report to all relevant team for the IP files completeness.
3. Follow up and collect all the discharged IP files within 24 hours of the patients discharge.
4. Follow up for the completeness of incomplete files within 72 hours.
5. Tracking the medical records which are not received to MRD.
6. Maintaining MLC permanently in the locker and inpatient and death files medical records separately with proper documentation
7. Cross check the meeting files (M&M) before uploading it to the HMIS & sending the files to Quality and Doctors
8. Post-receiving the confirmation from quality upload the M&M IP file, which is scheduled for that month in HMIS and inform the quality.
9. Distributing of IP files for MRR committee members for Audit purpose every week
10. Conducting IP files audit and discussing the Non compliances in the MRR Committee
11. Indent the required stationeries from the store and maintain stock book
12. As and when the request received from front office for medical records copy, MRD staff should reach spot and collect the medical record request form and file the same.
13. All OP files should be cross checked online for the coding, nutritional screening, nurse’s record, and consultation notes.
14. Data capturing and entering MRD CQIs in QIS before 5th of every month
15. RCA and CAPA should be prepared when the result / value cross the target and threshold level & presents the same in the CQI meeting
16. The compiled census data has to be updated to the IHIP Portal every day without fail
17. Updating TB data to the Nikshay portal as and when available
18. Monthly statistics to all doctors and relevant member’s statistics should include number of admissions, discharges, death, DAMA, MLC, IHIP, TB, notifiable diseases.
19. Updating monthly task report before 3rd of every month for the project sync meeting
20. All scanned files should do the quality check, update CQI, and discard the same
21. Conduct audits on IP coding, IP OT notes, IP file scanning.
22. All IP files including daycare should be scanned on a monthly basis.
23. Daily deficiency checking of the online files and sending the same to the concerned doctors on the same day
24. Arrange the files according to their retention period for shredding, get approval from the concerned authority after approval, processed with the shredding process
25. Appointments files should be sent to the doctors cabin as per their request within 10 minutes and before sending cross check the files
26. Check the hard disc working condition with the help of IT during back up.
1. Deficiencies found in the M&M meeting should be completed and updated to quality on the same
2. Scheduling the MRR committee meeting, preparing the PPT, preparing the comparison data, presenting the audit reports and presenting the issues which are related to medical records in the MRR committee meeting
Will Participate
1. Attend departmental meetings and meetings organized by the hospital
2. Medical records review committee meeting
3. Quality committee meeting
4. Quality Indicator meeting
5. Attend codes and disaster drills conducted in-house
6. Participate in the internal & external training organized by the hospital
7. Participate in internal & external audits conducted from quality department
Will Supervise:
1. Supervise the cleanliness of the department
2. Supervising for damages pages and changing damage folders
3. Supervising the department in the absence of HOD