1. Patient Record Management
- Maintains record of patient care by compiling, reviewing, and filing documentation of patient’s condition, treatment, and health outcome.
- Maintains medical records operations by following policies and procedures; reporting needed changes.
- Initiates medical record by searching master patient index; identifying existing patient records or need to assign a new number; interacting with registration areas and physician’s offices for information verification; processing or creating the record folder.
- Ensures medical record availability by routing records to admissions and emergency departments, physicians, and other authorized hospital staff; maintaining chart location systems.
- Completes medical record by reviewing information; notifying health care providers of record deficiencies; tracking outstanding records.
- Resolves medical record discrepancies by collecting and analyzing information and making necessary corrections.
2. Medical Data Coding
- Maintains historical reference by abstracting and coding clinical data, such as diseases, operations, procedures, and therapies, using standard classification systems; filing documents.
- Consult classification manuals to locate information about disease processes.
3. Privacy & Legal Compliance
- Maintains the stability and reputation of the hospital by complying with legal requirements.
- Maintains patient confidentiality and protects hospital operations by keeping information confidential; following release-of-information protocols.
- Releases information to persons or agencies according to regulations.
4. Reporting & Statistics
- Prepares statistical reports by collecting and summarizing medical care and census information, surgery performed, and use of hospital beds.
- Prepares narrative reports or graphic presentations of information, such as tumor registry data for hospital staff or researchers.
- Compiles census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
5. Information Requests & Department Oversight
- Provides medical record information by answering questions and requests from patients, staff, courts, insurance companies, and government agencies.
- Resolves or clarifies codes or diagnoses with missing or unclear information by consulting with doctors or participating in team meetings.
- Retrieves patient medical records for physicians, technicians, or other medical personnel.
- Plans, develops, or operates record indexes or systems to collect, store, or analyze health information.
- Compiles and maintains patient medical records to support treatment documentation, research, or care improvement.
- Manages the medical record department or supervises clerical staff.
- Develops in-service educational materials.
Education - Diploma in Medical Records Technology
Experience - 1 - 5 years
Job Type: Full-time
Pay: ₹18,000.00 - ₹28,000.00 per month
Work Location: In person