Responsible for carrying-out all procedures as they relate to the organization of all patient medical record files.
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Responsible for assembly and analysis (OP / IP), loose report filing, creating new folders after the discharge of the patient. To ensure that each in-patient medical records contains necessary documentation, reports, tests results, or other required elements as per departmental policy based on CBAHI & JCIA standards.
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Retrieve record as requested.
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Responsible for notifying all physicians of their incomplete medical records monthly to comply with hospital policy. All queries from Physicians are referred to this policy.
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Proper file maintenance has to be maintain in the master record filing area.
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Auditing of files will be carried-out.
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Is able to work independently with minimal direct supervision.
˙˙Maior Duties and ResponsibilitiesOutpatient Record Retrieval / Filing˙˙
Retrieves all medical records upon request (walk-in patients and ER patients)
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Retrieves pre-appointment records for next day outpatients visits and filing of the visited patients record in permanent filing area.( 1˙st˙& 2nd˙shift, i.e. 08:00 ? 16:00 & 16:00 -
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Reviews and assembles all patient files after retrieval.
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Prepares medical record folders for new patients.
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Inserts all incoming reports throughout each shift to prevent backlog.
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Maintains all shelving areas in accurate terminal digit order by periodically performing file audits.
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Complies with all departmental the policies and procedures.
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Routing the records to the outpatient and inpatient departments when its urgently needed for the patient care.
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Maintains accurate, neat files in a timely manner.
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Maintains confidentiality, security and personal privacy of all patient information and files.
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Places records on appropriate shelving area, i.e. permanent filing area, incomplete, coding and etc.
˙˙Assembly and Analysis˙˙
Responsible for collection of medical records discharges not forwarded to Medical Record Department.
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Assemble the unorganized document according to the standard assembling order (CBAHI & JCIA standard) of the discharged patients records.
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Analyze the medical record file for missing documents as per policy.
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Assigned to every physicians responsible for dictation of Surgical Procedure Report and Discharge Summary.
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Maintains accurate, neat files in a timely manner.
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Maintains confidentiality, security and personal privacy of all patient information and files.
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Maintains the computerized Medical Record Deficiency system.
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Work is conducted in a professional manner maintains patient / staff confidentiality when required.
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Participates in on-going education program developed by the department, e.g. department polices and procedures, Fire and Safety, Risk Management, Environmental control.
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Re-analyzes all medical records determined to be completed before filing in the permanent file area.
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Submits a weekly and monthly report on the number of delinquent records by physician department and type of deficiencies, i.e. signature, H & Ps, operation notes and discharge summaries as per policies.
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Performs applicable tasks and duties assigned within the realm of the employees knowledge, skills and duties.
