Discharge Summary Executive

Job Summary

The Discharge Summary Executive is responsible for preparing accurate, complete, and timely discharge summaries in coordination with treating doctors and clinical teams. The role ensures compliance with hospital policies, medical standards, and regulatory requirements while maintaining confidentiality and quality documentation.

Key Responsibilities

• Prepare, format, and finalize discharge summaries accurately and within defined timelines.
• Coordinate with consultants, residents, nursing staff, and allied departments to collect complete clinical information.
• Ensure discharge summaries comply with hospital protocols, NABH standards, and legal documentation requirements.
• Review discharge documents for accuracy, clarity, medical terminology, and completeness before finalization.
• Update electronic medical records (EMR/HIS) with finalized discharge summaries.
• Ensure proper documentation of diagnosis, treatment, procedures, investigations, and discharge instructions.
• Maintain confidentiality and security of patient medical records at all times.
• Handle corrections, amendments, and clarifications as instructed by consultants.
• Support audits, medico-legal documentation, and quality improvement initiatives.
• Adhere to turnaround time (TAT) standards for discharge summary completion.

Qualifications & Skills

• Bachelor’s degree in any discipline (preferably Life Sciences / Health Information Management).
• Diploma or certification in Medical Transcription / Medical Records preferred.
• Good knowledge of medical terminology and clinical documentation standards.
• Proficiency in computer applications and Hospital Information Systems (HIS).
• Strong attention to detail and accuracy.
• Excellent written communication skills in English.
• Ability to work under pressure and meet strict deadlines.
• Strong coordination and teamwork skills.

Experience

• 1–3 years of experience in discharge summary preparation, medical documentation, or hospital records (preferred).
• Freshers with relevant training may also be considered.

Key Competencies

• Documentation accuracy
• Time management
• Confidentiality & compliance
• Communication & coordination
• Quality orientation

Job Types: Full-time, Permanent

Pay: ₹15,000.00 - ₹25,000.00 per month

Benefits:

• Flexible schedule
• Health insurance
• Paid sick time
• Paid time off
• Provident Fund

Work Location: In person